Skip to main content
Internet Archive's 25th Anniversary Logo

Full text of "Journal of the Medical Association of the State of Alabama"

See other formats


Boston 

Medical  Library 
8 The  Fenway 


Digitized  by  the  Internet  Archive 
in  2016 


https://archive.org/details/journalofmedical3019alab 


4 

r 


IP? 

^ ‘I 


( 


’S'*'- : 


THE  JOURNAL 

of 

THE  MEDICAL  ASSOCIATION  OF  THE  STATE  OF  ALABAMA 

Published  Under  the  Auspices  of  the  Board  of  Censors 
Vol.  30  July  1960  No,  1 


MENTAL  CHANGES  IN  THE  AGING 
JAMES  N.  SUSSEX,  M.  D.* 


The  word  “aging”,  being  a present  parti- 
ciple, implies  a process.  Choosing  an  age 
zone  in  which  this  process  occurs  is,  in  many 
ways,  a matter  of  personal  choice.  Since 
some  investigators  consider  the  peak  of 
certain  physical  functions  as  occurring  in  the 
twenties,  one  could  take  this  as  a starting 
date  for  the  aging  process.  By  whatever 
criteria,  aging  is  a highly  individual  matter. 
One  person  of  60  may  have  the  physical  and 
mental  vigor  of  a 45-year-old  while  another 
the  same  age  may  look  and  act  as  though  he 
is  75  or  80.  The  age  which  is  currently  re- 
garded as  that  at  which  a person  becomes  a 
“senior  citizen”  is  65  years.  For  the  pur- 
poses of  this  discussion,  it  seems  wise  to  use 
this  arbitrary  figure. 

4 

The  statistics  of  aging  are  interesting  and 
a few  of  them  are  pertinent  to  this  discus- 
sion.■ It  is  reported  that  in  1900  there 
were  something  over  3 million  people  in  this 
country  65  years  of  age  and  older.  By  1920 
this  number  had  risen  to  over  4 million,  by 
1940  to  more  than  9 million  and  currently  to 
about  15  million.  About  20  million  are  ex- 
pected by  1975.  Whereas  now  about  109< 
of  the  population  is  65  years  of  age  or  older, 
it  is  estimated  that  in  1980  about  15%  of 
the  total  population  will  be  in  this  group. 
That  the  elderly  constitute  and  will  increas- 
ingly constitute  a major  part  of  medical 


*From  the  Department  of  Psychiatry,  Medical 
College  of  Alabama.  Presented  before  the  Ala- 
bama Academy  of  General  Practice,  20th  Post- 
graduate Seminar,  Birmingham,  January  20,  1960. 


practice  is  recognized  in  almost  all  medical 
publications.  Only  recently,  however,  have 
organizations  such  as  this  one  begun  to  turn 
their  attention  specifically  to  some  of  the 
problems  relevant  to  this  age  group. 

The  doctor’s  role  in  treating  older  people 
is  perhaps  more  of  a two-fold  one  than  is 
usual  in  medical  practice  with  younger 
adults.  It  is  similar  to  that  of  the  pediatri- 
cian in  that  he  will  be  expected  not  only 
to  treat  various  things  gone  wrong  with  the 
aging  person  but  also  to  perform  an  impor- 
tant preventive  function.  In  pediatrics,  pre- 
vention is  geared  to  promotion  of  good  nutri- 
tion, avoidance  of  severe  contagious  diseases, 
and  protection  of  the  child  so  he  can  develop 
physically,  mentally  and  emotionally  in  a 
normal  way.  With  the  aged  person  it  also 
includes  maintaining  proper  nutrition  as  well 
as  preventing  accidents  which  might  result 
in  long  periods  of  crippling,  slowing  down 
deteriorative  processes  as  much  as  possible, 
and  preventing  the  development  of  unhealthy 
emotional  patterns.  Good  health  in  the 
elderly  is,  as  Dr.  Frederick  Swartz  told  a 
Senate  Labor  Subcommittee  on  Aging,  “more 
than  the  absence  of  disease  or  infirmity”,  it 
is  also  the  “positive  state  of  physical,  mental 
and  social  well-being”.'*  The  physician  will 
be  expected  to  be  in  the  forefront  of  any 
efforts  to  accomplish  this. 

In  discussing  the  mental  changes  of  the 
aging,  perhaps  it  would  be  best  to  enumerate 
some  of  the  mental  symptoms  which  are 
frequently  seen  in  this  age  group.  Examples 


MENTAL  CHANGES  IN  THE  AGING 


of  mild  symptoms  of  this  sort  are  restless- 
ness, irritability,  forgetfulness  and  absent- 
mindedness,  circumstantiality  of  conversa- 
tion and  tendency  toward  hypochondria.  More 
serious  symptoms  are  emotional  fluctuation 
of  wider  range  (particularly  despondency), 
suspiciousness,  agitation,  memory  gaps  (par- 
ticularly for  recent  events),  over-concern 
with  the  past,  confabulation  and  social  with- 
drawal. At  the  level  of  greatest  severity  we 
see  mental  confusion,  disorientation  (espe- 
cially as  to  time  but  not  infrequently  also 
for  place  or  person),  rambling  of  speech  to 
the  point  of  incoherence,  gross  disorganiza- 
tion of  thinking,  assaultiveness,  destructive- 
ness, lack  of  concern  about  physical  appear- 
ance, paranoid  ideas  of  persecution,  and  oc- 
casionally hallucinations.  At  any  level  there 
may  be  some  behavioral  abnormalities  and 
some  degree  of  impaired  judgment  and  ap- 
parent difficulty  in  comprehending.  Even 
at  the  milder  levels,  the  patient  is  frequently 
described  as  resistive  to  change,  slow  to 
adapt  to  changing  circumstances  and  unable 
to  learn  new  things  effectively.  Any  given 
individual  may  show  any  of  these  symptoms 
in  any  combination.  He  may  appear  marked- 
ly impaired  in  one  area  of  function  and  al- 
most intact  in  others. 

Probably  for  convenience  we  can  divide 
mental  symptoms,  regardless  of  severity,  into 
three  groups:  (1)  those  associated  with  and 
presumably  caused  by  significant  structural 
or  physiologic  pathology  of  the  brain;  (2) 
those  associated  with  but  not  clearly  the 
result  of  demonstrable  brain  pathology;  and 
(3)  those  associated  with  no  demonstrable 
pathology  of  the  brain. 

It  is  extremely  difficult  to  decide  into 
which  group  any  given  patient  should  be 
placed.  Commonly  nowadays,  if  we  see 
some  of  the  symptoms  described  above  and 
also  find  some  A — V nicking  in  the  fundi 
or  blood  pressure  beyond  the  range  of  nor- 
mal, we  tend  to  consider  the  mental  changes 
as  the  result  of  cerebral  arteriosclerosis  or 
hypertensive  encephalopathy.  Yet  we  see 
other  patients  with  comparable  degrees  of 
arteriosclerosis  or  hypertension  who  show 
no  mental  symptoms  at  all.  The  differen- 


tiation is  not  merely  an  academic  question. 
It  is  of  profound  consequence  to  the  patient 
himself  and  to  society  at  large. 

If  he  becomes,  because  of  his  mental  symp- 
toms, so  difficult  to  get  along  with  at  home 
that  hospital  care  is  indicated,  the  chances 
are  good  that  he  will  be  sent  to  a mental  in- 
stitution with  a diagnosis  of  senile  psychosis. 
Implicit  in  the  physician’s  use  of  this  term 
is  his  belief  that  the  patient’s  symptoms  are 
caused  by  irreversible  organic  changes  in 
the  brain.  If  this  is  the  diagnosis  and  dispo- 
sition chosen,  the  chances  are  good  that  it 
will  be  a permanent  arrangement.  Few 
old  folks  who  go  into  a state  hospital  ever 
again  emerge.  This  is  important  not  only 
to  the  individual  patient  but  also  to  the  tax- 
payer since  it  has  been  reported  nationally 
that  about  one-third  of  first  admissions  to 
public  mental  institutions  are  65  years  of 
age  and  older. ^ 

If  these  patients  are  all  psychotic,  a rec- 
ommendation for  commitment  by  the  physi- 
cian is  justified.  If  the  condition  is  irre- 
versible, permanent  hospitalization  may  be 
necessary.  It  is  the  contention  of  many  ex- 
perts in  the  field  of  aging,  however,  includ- 
ing not  just  psychiatrists  but  internists  and, 
most  particularly,  generalists  who  are  most 
familiar  with  the  problem,  that  many  elderly 
patients  who  are  committed  are  not  psy- 
chotic but  are  institutionalized  because  they 
are  an  inconvenience  to  the  family  or  have 
nowhere  else  to  go.  Some  of  these  patients 
might  far  better  be  taken  care  of  in  an  ade- 
quate nursing  home  or,  as  I will  mention 
later,  might  be  able  to  remain  at  home  if  cer- 
tain resources  were  available.  Even  for  those 
who  are  psychotic,  institutionalization — at 
least  in  the  traditional  state  hospital — may 
not  be  the  preferable  course  of  action.  Many 
patients  with  psychoses  associated  with  or- 
ganic cerebral  disease  can  be  treated  and 
rehabilitated  in  their  own  communities,  espe- 
cially those  in  whom  hypertension  or  defi- 
cient cerebral  oxygenation  is  the  causative 
factor.  Many  of  those  whose  psychoses  are 
not  associated  with  demonstrable  organic 
pathology  can  also  be  treated  successfully  if 
proper  facilities  are  available. 


2 


J.  M.  A.  ALABAMA 


MENTAL  CHANGES  IN  THE  AGING 


How  can  we  decide  which  mental  changes 
are  reversible,  which  irreversible,  which  pa- 
tients require  institutionalization  and  which 
can  be  helped  most  by  some  other  course 
of  action?  As  Smigel  said  in  1956,  “Before 
one  can  come  to  grips  with  the  problem,  one 
has  to  determine  what  the  problem  is.”''  Al- 
though there  are  marked  individual  differ- 
ences, there  are  certain  physical  signs  that 
we  regularly  associate  with  aging.  There 
tends,  for  example,  to  be  a general  increase 
in  body  bulk  with  resultant  apparent  changes 
in  body  build.  Abdomen,  hips  and  thighs 
become  heavier  and  more  prominent  and  the 
fleshy  bulk  around  the  shoulder  girdle  less 
prominent.  Postural  changes  emphasize  this 
difference  in  physical  appearance.  Agility 
is  decreased  and  motor  acts  become  slower, 
more  labored  and  less  sure.  When  one  con- 
siders that  elastic  connective  tissue  is  laid 
down  in  decreasing  amounts  as  an  individual 
ages  and  that  collagen  is  deposited  in  in- 
creasing amounts  with  resultant  loss  of  elas- 
ticity and  flexibility  of  the  body  tissues  gen- 
erally, one  might  conclude  that  these  changes 
in  appearance  and  physical  function  are 
automatic  and  inevitable  results  of  the  physi- 
cal aging  process.  One  could  wonder,  how- 
ever, about  the  possible  effect  of  psychologi- 
cal phenomena  in  contributing  to  the  devel- 
opment of  the  picture  of  the  gradually  more 
infirm  aging  individual.  Is,  for  example,  the 
round-shouldered  posture  so  frequently  seen 
in  older  people  the  result  of  a lessened  physi- 
cal capacity  for  standing  up  straight  or  is  it, 
at  least  in  part,  the  result  of  a mental  atti- 
tude which  makes  it  no  longer  worthwhile 
for  that  individual  to  try  to  stand  up  straight? 
We  have  all  seen  women  who  have  remained 
physically  active!  until  the  death  of  their 
husbands,  after  which  time  they  rapidly 
took  on  the  appearance  of  much  older  and 
less  firm  people.  Similarly,  we  are  all  surely 
acquainted  with  men  who  have  remained 
vigorous  and  essentially  youthful-looking 
until  retirement,  following  which  they 
showed  rapid  physical  decline  with  the  ap- 
pearance of  the  stigmata  we  have  come  to 
associate  with  senility.  To  even  the  most 
casual  observer  it  would  seem  that  factors 


other  than  physiologic  and  anatomic  deteri- 
oration are  involved. 

To  what  extent  are  deteriorative  changes 
in  the  brain  responsible  for  some  of  the  men- 
tal changes  which  occur  in  elderly  patients? 
At  autopsy  the  meninges  are  frequently 
found  to  be  thickened  and  adherent  and 
sometimes  show  patches  of  calcification  and 
ossification.  The  cerebrum  shows  some  de- 
gree of  general  atrophy  and  formations  of 
various  kinds,  known  as  senile  plaques.  The 
cerebellum  also  shows  general  atrophic 
changes,  as  does  the  spinal  cord,  with  an  in- 
crease in  fibrous  components  (neuroglia) 
and  sometimes  irregular  and  patchy  degen- 
eration of  myelin  sheaths.  In  a patient  who 
has  shown  considerable  mental  changes  be- 
fore death,  it  would  appear  that  such  brain 
pathology  affords  adequate  explanation.  Yet 
there  are  many  reports  of  brain  autopsies  in 
which  such  organic  changes  have  been  found 
without  any  history,  in  the  day-to-day  life 
of  the  individual  before  his  death,  of  sig- 
nificant mental  changes  which  we  ordinarily 
associate  with  aging.  It  would  appear  that 
there  is  little  certain  evidence  at  this  time 
that  there  is  direct  connection  between  the 
amount  of  physical  degenerative  change  in 
the  brain  and  the  mental  status  of  the  indi- 
vidual in  whose  brain  these  changes  occur. 
The  clinical  manifestations  seem  to  be  a prod- 
uct of  a great  many  factors  other  than  or  in 
addition  to  the  demonstrable  deteriorative 
processes  of  the  brain  itself. 

What  does  happen  then?  It  has  been  held 
by  many  investigators-'^’ that  even  in  the 
late  twenties  or  early  thirties  there  is  some 
slowing  down  in  skilled  activity  as  measured 
by  objective  testing,  which  is  essentially  due 
to  physical  wearing  out  of  the  body  in  gen- 
eral. This  is  characteristically  accompanied 
by  recovery  of  any  lost  skill,  probably  as  the 
result  of  the  individual’s  using  past  expe- 
rience and  more  mature  judgment  as  compen- 
satory measures.  Again  in  the  late  thirties 
and  early  forties  there  is  some  slow-up  of 
skilled  activity,  and  there  is  again  usually 
sufficient  recovery  that  a man  in  this  age 
group  and  into  the  early  fifties  can  be  con- 
sidered in  many  ways  at  his  prime.  In  the 


JULY  I960— VOL.  30,  NO.  I 


3 


MENTAL  CHANGES  IN  THE  AGING 


middle  fifties  there  is  a third  period  during 
which  a slow-up  in  skilled  activity  is  defi- 
nitely demonstrable  and,  following  this  par- 
ticular period,  there  is  seldom  any  recovery 
of  significant  degree.  Generally  speaking, 
there  is  a gradual  and  progressive  decline  in 
certain  skills  from  that  point  onward.  In  a 
competent,  well-adjusted,  healthy  individual, 
this  is  usually  nothing  dramatic  and  may  be 
essentially  imperceptible  for  several  years, 
maybe  even  three  or  four  decades.  In  other 
individuals,  the  changes  may  be  catastrophic. 

These  processes  particularly  involve  three 
areas  of  function. First,  the  individual’s 
sensory  acuity  decreases.  He  is  no  longer 
able  to  perceive  certain  stimuli  that  he  once 
perceived  without  difficulty  and  this  renders 
him  to  some  degree  less  in  his  environment 
than  he  was  before.  We  are  all  familiar  with 
the  grosser  evidences  of  this,  especially  in 
the  senses  of  hearing  and  sight.  Secondly, 
his  reaction  time  increases.  It  takes  him 
somewhat  longer  to  get  into  motion,  muscu- 
lar or  mental,  from  the  time  he  initially  per- 
ceives the  stimulus  which  requires  the  ac- 
tion. Thirdly,  his  memory  span  is  somewhat 
shorter  than  before. 

The  elderly  person  is  frequently  regarded 
as  being  considerably  handicapped  by  these 
developments,  and,  to  be  sure,  sensory  deficits 
may  become  so  marked  that  activity  must 
be  curtailed.  Frequently,  however,  the 
shortened  memory  span  and  lengthened  re- 
action time  are  regarded  as  contributing  to 
vocational  and  social  inadaptability  to  a de- 
gree incompatible  with  productive  activity 
or  even  group  participation  of  any  sort.  To 
evaluate  the  validity,  or  lack  of  validity,  of 
such  an  attitude  we  must  consider  the  na- 
ture of  learning,  since  this  is  essentially  what 
adaptation  is. 

We  are  all  familiar  with  the  old  adage, 
“You  can’t  teach  an  old  dog  new  tricks”.  It 
is  apparently  true  that  from  about  the  fifties 
onward,  attempts  to  adapt  to  new  conditions 
of  performance  and  new  types  of  stimulation 
are  likely  to  require  a relatively  longer  learn- 
ing stage  than  before.  Although  reaction  time 
may  be  an  important  factor  in  learning  new 
skills  or  in  carrying  out  learned  acts  effec- 


tively, in  recent  experiments  by  various  in- 
vestigators’" it  has  appeared  that  perhaps 
this  is  not  the  most  significant  element  in  the 
picture.  These  tests  seem  to  indicate  that 
it  is  the  resting  or  recovery  time  following 
a reaction  which  is  the  important  factor.  One 
of  the  characteristic  features  of  the  aging 
person  is  that  he  does  not  recover  as  rapidly 
following  a reaction  as  he  did  when  he  was 
younger.  He  needs  a longer  rest  period  to 
be  ready  for  the  next  stimulus  than  he  did  in 
earlier  years.  Recognition  and  acceptance 
of  this  fact  can  help  us  change  our  attitudes 
toward  what  we  expect  from  older  people  in 
situations  which  require  of  them  readjust- 
ment or  readaptation — in  other  words,  in  sit- 
uations which  require  new  learning.  The 
learning  process  of  the  older  person  must 
take  place  in  a different  manner  from  that 
of  a younger  person.  He  must  be  given 
more  time  in  which  to  recover  between 
each  completed  action  and  the  next  following 
stimulus  for  a succeeding  action.  This  does 
not  mean,  however,  that  we  need  necessarily 
expect  any  lesser  ultimate  capacity  from  the 
older  person  in  areas  for  which  he  has  the 
necessary  experience,  basic  intelligence  and 
physical  capacity. 

Signs  of  breakdown  of  an  older  person’s 
ability  to  adapt  to  new  situations — that  is, 
to  learning  situations — can  be  recognized  by 
an  alert  observer.  Normally  a signal  or 
stimulus  will  produce  an  appropriate  reac- 
tion. If  the  signals  come  in  too  rapidly  for 
the  individual  to  handle,  the  first  sign  of 
maladjustment — or  of  pathology,  if  you  will 
— would  be  the  appearance  of  mistakes.  We 
all  have  a tendency  to  repeat  actions  based 
on  earlier  learning  patterns,  especially  when 
we  are  under  stress  and,  therefore,  tense  and 
anxious.  If  a mistake  is  learned  as  part  of 
a pattern,  one  thing  we  should  expect  patho- 
logically is  the  persistence  of  mistakes  there- 
after. If  stimuli  continue  to  originate  in  the 
environment  so  fast  that  the  elderly  person 
does  not  have  an  adequate  recovery  period, 
there  may  be  a point  at  which  no  reaction  at 
all  is  possible.  If  the  stimulus  catches  the 
person,  literally,  in  the  refractory  stage,  he  is 
incapable  of  making  even  an  erroneous  re- 


4 


J.  M.  A.  ALABAMA 


MENTAL  CHANGES  IN  THE  AGING 


sponse.  When  an  elderly  person  makes  re- 
peated mistakes  or  appears  unable  to  respond 
at  all,  he  is  frequently  regarded,  at  best,  as 
uncooperative  or  stubborn  or  even  as  senile 
and  deteriorated.  In  either  case,  this  misun- 
derstanding may  lead  to  his  being  rejected 
on  the  assumption  that  he  is  hopelessly  un- 
able to  be  useful  or  productive. 

Also  often  contributing  to  this  impression 
of  mental  deterioration  are  forgetfulness, 
especially  for  recent  events,  and  apparently 
impaired  reasoning  and  judgment.  Psycholo- 
gists think  they  can  demonstrate  with  the 
standard  intelligence  tests  that  there  is  char- 
acteristically a gradual  lowering  of  scores  as 
a person  grows  older.  They  have  formulated 
a more  or  less  standardized  curve  by  which 
an  individual’s  score  can  be  compared  to  a 
presumed  norm  for  his  age  and  a “deteriora- 
tion index”  determined.  What  is  measured, 
of  course,  is  performance  and  there  is  some 
doubt  that  this  is  a valid  indication  of  actual 
intellectual  capacity,  since  in  any  test  situa- 
tion learning  is  involved  and  the  slowing 
down  of  the  learning  process  as  a person 
grows  older  would  tend  to  lower  his  achieve- 
ment score.  Where  allowance  can  be  made 
for  this  slower  learning,  it  would  appear  that 
basic  intelligence  does  not  decline  auto- 
matically, certainly  not  materially,  as  a re- 
sult of  normal  aging.  There  is  need  for  solid 
research  in  the  area  of  learning.  Most  of  the 
research  done  thus  far  is  concerned  with 
learning  achievement  rather  than  learning 
process.-^  The  details  of  the  process  by  which 
learning,  and  therefore  adaptation,  occurs  is 
almost  entirely  neglected. 

One  of  the  factors  involved  in  the  dimin- 
ished capacity  of  many  older  individuals  to 
adjust  easily  and  quickly  to  new  situations 
is  an  extension  of  something  which  happens 
to  all  of  us  every  day.  We  know,  for  example, 
that  a two-year-old  youngster  can  learn 
French  or  Chinese  just  as  easily  as  he  can 
learn  English.  After  he  has  learned  English, 
however,  it  is  no  longer  as  easy  for  him  to 
learn  French  or  Chinese  and  the  older  he  gets, 
the  harder  it  will  be.  This  is  not  because  he 
is  less  intelligent.  It  is  because  once  we  have 
learned  something  and  have  established  a 


pattern  for  ourselves,  we  tend  to  use  that 
pattern  automatically  under  stress.  Trying 
to  learn  something  new  is  stressful  and  we 
not  only  have  to  learn  the  new  thing  but, 
literally,  to  unlearn  or  at  least  get  out  of  the 
habit  of  automatically  using  the  old.  The 
more  years  we  live,  the  more  patterns  we 
have  crystallized  into  rigid,  semi-automatic 
sequences  and  the  more  difficult  it  is  to  aban- 
don them.  There  is  strong  temptation  for  all 
of  us  to  take  the  easier  way  and  to  cling  to  the 
old  habits  of  thought  and  attitude.  The 
elderly  person  is  especially  likely  to  do  that. 

One  must,  of  course,  consider  whether  such 
symptoms  are  the  specific  products  of  or- 
ganic changes  in  the  brain.  In  certain  condi- 
tions of  gross  deterioration  of  the  brain,  such 
as  Pick’s  or  Altzheimer’s  disease,  we  know 
that  judgment  is  impaired  on  an  apparently 
organic  basis.  We  also  know,  however,  that 
impaired  judgment  is  part  of  many  so-called 
“psychogenic”  psychotic  pictures,  such  as 
schizophrenia  or  manic-depressive  psychosis. 
Furthermore,  we  see  occasional  X-ray  or 
autopsy  evidence  of  marked  cerebral  atrophy 
of  the  Pick’s  or  Altzheimer’s  type  without  any 
signs  or  symptoms  of  mental  or  emotional 
difficulty.  Clearly  there  is  no  definite  and 
direct  correlation  between  the  preservation 
or  deterioration  of  mental  faculties  and  the 
presence  or  absence  of  organic  brain  disease. 
This  makes  it  all  the  more  necessary  to  won- 
der, when  one  sees  defective  judgment,  ap- 
parently lessened  comprehension  and  other 
signs  of  mental  impairment  in  an  elderly 
patient,  if  the  cause  lies  in  the  emotional 
area.  Such  syndromes  can  certainly  result 
from  the  patient’s  uncertainty  and  lack  of 
confidence  resulting  from  his  recognition  of 
his  slower  adaptation  to  new  situations  and 
his  greater  tendency  to  make  mistakes.  And 
after  being  rejected  because  of  these  diffi- 
culties, he  may  soon  lose  any  motivation  he 
once  had  for  being  any  different. 

It  has  been  noted  that  brighter  individuals 
tend  to  deteriorate  less  obviously  in  the 
course  of  normal  events  than  do  those  of 
lesser  intelligence.  This  is  probably  because 
the  brighter  person  has  more  to  fall  back  on. 
When  an  older  person’s  reasoning  and  judg- 


JULY  I960— VOL  30,  NO.  I 


5 


MENTAL  CHANGES  IN  THE  AGING 


merit  is  regarded  as  impaired,  most  frequent- 
ly the  impairment  shows  up  in  areas  which 
are  least  familiar  to  him.  If  he  has  wide 
experience  or  skill  in  some  particular  field 
of  endeavor,  it  is  much  less  likely  that  his 
judgment  and  reasoning  will  be  impaired  in 
these  areas.  The  wider  his  interests  and  ac- 
complishments have  been,  the  more  likely  it 
is  that  he  will  maintain  his  mental  powers 
relatively  intact.  Ability  to  interpret  mean- 
ings and  to  recognize  relationships  in  areas 
which  are  familiar  to  the  older  person  tends 
not  to  be  lost.  General  information  does  not 
decline  significantly  and  vocabulary  tends 
to  be  maintained.  It  also  appears  that  cre- 
ative imagination,  provided  there  was  some 
there  in  the  first  place,  tends  to  be  ageless. 
Although  it  has  been  pointed  out  that  many 
of  the  most  imaginative  and  creative  ideas 
and  works  of  man  have  been  produced  by 
individuals  in  their  early  or  middle  thirties, 
the  genius  of  most  creative  men  continues 
to  display  itself  well  into  the  age  group 
which  would  ordinarily  be  considered  senile. 

In  summary,  the  mental  changes  occurring 
in  the  elderly  person  involve  many  consid- 
erations. There  are  some  mental  changes 
which  may  represent  a psychotic  or  psycho- 
neurotic illness  which  is  not  peculiar  to  the 
aged  at  all  but  could  occur  at  any  age.  There 
are  some  changes  which  result  from  specific 
pathology  of  the  brain.  There  are  some 
changes  which  reflect  lessened  adaptability 
as  a consequence  of  the  need  for  a longer 
rest  period  between  one  action  and  the  next- 
following  actions.  Lastly,  there  are  mental 
changes  which  are  solely  psychological  and 
reflect  the  elderly  person’s  fear,  lack  of  con- 
fidence, feeling  of  rejection,  resentment  of 
his  status,  lack  of  motivation  and  unwilling- 
ness to  reorganize  his  attitudes  and  ways  of 
thinking  about  or  of  doing  things.  When 
motivation  is  absent,  the  gradually  diminish- 
ing interest  in  the  external  environment  leads 
to  decrease  in  intellectual  activity  and  as  a 
result  of  this  disuse,  decline  and  deteriora- 
tion is  accelerated.  Mental  changes,  from 
whatever  cause,  can  be  relatively  mild  or 
they  can  be  so  severe  that  the  individual  must 
be  considered  psychotic. 


It  is  the  prevention  of  these  severe  states 
which  occur  not  as  the  result  of  organic  brain 
disease  that  concern  us  most.  What  indica- 
tions are  there  that  this  can  be  accomplished? 
Howard  Rusk,  in  the  December  1958  issue  of 
GP,  cites  some  pertinent  experience.’  He 
described  it  as  follows:  “Fourteen  years  ago 
in  the  Bronx,  welfare  workers  couldn’t  get 
their  work  done  because  there  was  a con- 
stant stream  of  old  people  coming  by  all  day 
with  some  kind  of  complaint.  Finally  one 
worker  said,  T don’t  think  these  people  have 
anything  to  complain  about;  they  just  don’t 
have  any  place  to  go’  . . . So  they  furnished 
three  rooms  in  an  abandoned  city  hall  with 
an  old  piano,  pool  table  and  card  tables  . . . 
Five  years  later  the  club  they  set  up  for 
these  old  people  had  700  members,  aged  65 
to  96  (with  an  average  age  of  76).  They 
had  shops,  a weekly  dance,  and  a monthly 
play  written  by  an  81-year-old  playwright. 
There  had  been  11  weddings.  When  the  sen- 
ior-center group  was  compared  with  a similar 
one  of  the  same  age  and  socio-economic  level, 
they  had  50  percent  less  hospital  admissions 
for  physical  illness,  and  their  visits  to  physi- 
cians and  clinics  had  dropped  50  percent.” 

The  American  Psychiatric  Association  has 
estimated  an  expected  40  psychotic  breaks 
requiring  admission  to  a mental  institution 
in  such  a group  over  a five-year  period.’  For 
the  group  cited,  the  records  failed  to  show 
any  admissions  at  all  for  senile  psychosis  dur- 
ing that  five-year  span.  As  a note  of  eco- 
nomic interest.  Dr.  Rusk  added  that  had  the 
eight  psychotic  illnesses  expected  each  year 
actually  developed,  the  cost  to  the  govern- 
ment, and  therefore  to  the  taxpayers,  to  pro- 
vide institutional  care  would  have  amounted 
to  $10,000  more  each  year  than  was  spent 
to  run  the  entire  center  for  these  700  senior 
citizens. 

This  is  not  an  isolated  experience.  Simi- 
lar reports  have  come  in  from  other  such 
centers.  The  evidence  may  not  meet  rigid 
research  criteria  but  the  implications  are 
clear.  Many  of  the  mental  changes  in  the 
aged,  severe  enough  to  be  called  psychotic, 
usually  termed  “senile  psychosis”  or  “senile 
dementia”,  attributed  to  so-called  “senile”  or 


6 


J.  M.  A.  ALABAMA 


MENTAL  CHANGES  IN  THE  AGING 


deteriorative  organic  brain  disease  and  con- 
sidered essentially  irreversible,  apparently 
occur  in  significantly  lesser  number  in  groups 
of  elderly  people  who  are  afforded  an  oppor- 
tunity to  participate  in  activities  which  foster 
feelings  of  acceptance,  belonging  and  useful- 
ness.Said  another  way,  it  would  appear 
that  a significant  cause  of  serious  mental 
symptoms  in  the  aged  person  is  his  feelings 
of  unwanted  and  resented  dependency,  lone- 
liness and  rejection  by  an  environment  which 
is  characteristically  inhospitable  and  often 
hostile. 

Dr.  Swartz,  in  his  testimony  before  the 
Senate  Labor  Subcommittee  on  Aging,  said, 
“Physicians  have  yet  to  find  an  antibiotic 
for  loneliness  and  rejection”.''  Yet  regard- 
less of  etiology  or  of  psychodynamics,  the 
practicing  physician  is  faced  daily  with  the 
necessity  of  treating  elderly  people  with 
a variety  of  complaints  which  need  attention 
now.  This  is  a “most  difficult  group  for 
whom  to  care  and  prescribe”,^  a frustrating 
experience  for  any  physician,  no  matter  how 
fully  he  understands  the  underlying  dynam- 
ics of  his  particular  patient’s  mental  symp- 
toms. It  is  easy  to  say  that  the  patient’s  ir- 
ritability is  the  expression  of  his  bitterness 
over  forced  dependency,  that  his  preoccupa- 
tion with  his  body  functions  is  a self-admin- 
istered unconscious  substitute  for  affection 
he  doesn’t  get  from  anyone  else,  that  his 
cantankerous  and  domineering  attitude  is  a 
distorted  result  of  his  loss  of  self-esteem  and 
inner  security,  that  his  obsessive  worries  re- 
flect his  deep-seated  loss  of  self-confidence, 
that  his  despondency  and  expressions  of 
hopelessness  represent  grief  over  lost  stature 
and  affection,  that  his  forgetfulness  and  pre- 
occupation with  the  past  is  his  way  of  turning 
away  from  a painful  present,  that  his  suspi- 
cious and  quarrelsome  attitude  is  a twisted 
cover-up  for  his  desire  to  belong  to  somebody, 
or  that  any  or  all  of  these  symptoms  might 
be  an  unconscious  means  of  obtaining  the  at- 
tention he  once  got,  or  of  dominating  his 
physician  to  regain  lost  status  or  of  express- 
ing his  anger  at  everyone,  fate  included,  be- 
cause things  are  as  they  are. 

It  is  easy  to  say  at  that  point  that  what  is 
JULY  I960— VOL.  30,  NO.  I 


needed  is  motivation  or  renewed  interest  or 
a feeling  of  belonging  or  a sense  of  being 
useful  to  somebody.  But  seldom  is  the  phy- 
sician in  a position  to  meet  these  needs,  no 
matter  how  clearly  he  recognizes  them  or 
how  much  he  tries.  He  can’t  inject  motiva- 
tion. He  can’t  prescribe  a changed  attitude. 
He  can  prescribe  a cerebral  stimulant,  per- 
haps, or  a diet  or  exercise.  He  can  also  help 
his  patient  regain  a little  of  his  dignity  by 
treating  him  with  respectful  attention  and 
willingness  to  try  to  understand.  Beyond 
that  the  physician  may  not  be  able  to  go 
unless  he  is  fortunate  enough  to  be  prac- 
ticing in  a community  which  has  already 
organized  facilities  similar  to  that  described 
by  Rusk.  If  such  exist,  the  physician’s  un- 
derstanding referral  may  be  the  first  step 
toward  rehabilitation.  If  it  is  a hostile  or 
rejecting  referral,  however  subtle  the  hos- 
tility may  be,  the  patient  will  know  it  and  the 
referral  will  in  all  probability  be  a failure. 
In  fact,  the  situation  will  be  worsened  be- 
cause the  patient  will  consciously  or  uncon- 
sciously resist  any  future  such  referral. 

What  we  need  to  do,  then,  as  physicians,  is 
to  express  our  professional  conviction,  if  we 
have  it,  that  the  kind  of  facilities  described  by 
Rusk  are  an  integral  part  of  the  total  neces- 
sary health  resources  of  every  community, 
that  such  facilities  will  do  much  to  combat 
undesirable  mental  changes  in  the  elderly 
and  that,  ultimately,  such  resources  will  save 
far  more  money  than  they  cost  by  keeping 
the  elderly  out  of  mental  hospitals.  This  will 
not,  of  course,  be  the  whole  solution.  The 
aging  process  still  goes  on  and  with  it  will 
come  ever  new  problems.  But,  in  the  words 
of  Hobson,  “If  we  cannot  yet  point  to  ways 
of  reversing  age  trends,  we  can  at  least  show 
how  their  effects  may  be  minimized”.-'*  Such 
a goal  is  certainly  in  keeping  with  the  highest 
ideals  of  medical  practice. 

REFERENCES 

1.  Gilbert,  J.  G.;  Understanding  Old  Age.  Ron- 
ald Press,  New  York;  422  p.,  1952. 

2.  Gitelson,  M.:  Emotional  Problems  of  Elderly 
People.  Geriatrics  3:  135-150,  May-June  1948. 

3.  Hobson,  W.:  Modern  Trends  in  Geriatrics. 

Paul  B.  Hoeber,  Inc.,  New  York:  422  p.,  1957. 

7 


MENTAL  CHANGES  IN  THE  AGING 


4.  Proctor,  R.  C.:  Management  of  Psychiatric 

Symptoms  Associated  with  Aging.  Clinical  Medi- 
cine, 6:  4,  June  1959. 

5.  Rusk,  H.  A.:  Stress  in  the  World:  The  In- 
dividual and  the  Doctor.  G.  P.,  18:  163-167,  De- 
cember 1958. 

6.  Sanders,  L.  C.:  Psychosomatic  Problems  of 

the  Aged.  Am.  Pract.  3:  169-173,  November  1958. 

7.  Shock,  N.  W.:  Trends  in  Gerontology  (2nd 
ed.).  Stanford  University  Press,  Stanford,  Cali- 
fornia: 214  p.,  1957. 

8.  Smigel,  J.  O.,  Mood  Therapy  in  the  Aged. 
Medical  Times,  85:  149-158,  February  1957. 

9.  Swartz,  F.  C.:  Testimony  before  Subcom- 

mittee on  Aging,  as  reported  in  AMA  News.  August 
10,  1959. 

10.  Wolstenholme,  G.  E.  W.  and  Cameron,  M.  P.: 
Ciba  Foundation  Colloquia  on  Aging.  Vol.  I,  Little, 
Brown  and  Co. — Boston,  255  p.,  1955. 


ALCOHOLISM 

DRUNKEN  DRIVING 

The  Case  for  Reducing  the  “Conclusive” 

Level  of  Blood  Alcohol  to  One  Part  Per 

Thousand. 

Doctors  in  Germany  have  often  stated  that 
a serum  alcohol  level  of  over  1 part  per  1000 
is  not  compatible  with  safe  driving,  but  the 
courts  put  the  limit  at  1.5  per  thousand,  al- 
lowing a margin  for  inexact  determination, 
individual  variation  and  so  on.  Recently  im- 
proved laboratory  methods  have  made  it 
possible  to  reduce  this  margin  for  errors. 
The  limit  of  1 part  per  1000  still  allows  the 
driver  to  consume  four  pints  of  beer,  six  to 
eight  stronger  drinks  like  gin,  or  many  glasses 
of  wine.  In  Norway,  Sweden  and  Denmark, 
the  highest  value  tolerated  by  law  is  0.5  per 
thousand. 

The  symptoms  of  intoxication  with  blood 
levels  under  1 part  per  1000  are  lack  of  in- 
hibitions, diminished  attention,  tendency  to 
take  undue  risks  and  an  increased  sensitiv- 
ity to  bright  lights.  A driver  should  abstain 
from  alcoholic  drinks  for  one  and  one-half 
hours  before  driving.  If  the  accident  risk  is 
put  at  one  in  drivers  who  have  had  no  drinks, 
it  rises  to  seven  in  drivers  with  an  alcohol 
level  of  0.3  to  0.99  per  1000,  to  31  with  a level 
of  1.0  to  1.49  per  1000,  and  to  128  with  levels 
over  1.5  per  1000. 

(From:  Medizinische  Monatsschrift,  World- 
Wide  Abstracts.) 


PEDIATRICS 

HYPERNATREMIA 

Concentrated  Formulas  Risk  the  Syndrome, 

Especially  in  Periods  of  High  Water  Loss. 

Hypernatremia  is  a clinical  syndrome  in 
which  the  serum  levels  of  sodium  and  chlo- 
ride are  markedly  raised.  The  syndrome  is 
associated  with  severe  dehydration.  Extreme 
thirst  is  a prominent  feature  of  the  earlier 
stages,  though  later  it  often  gives  place  to 
nausea  and  vomiting.  In  untreated  cases  the 
main  complication  is  involvement  of  the  cen- 
tral nervous  system,  with  lethargy,  hyper- 
irritability, tremors  and  occasionally  con- 
vulsions. Many  of  the  symptoms  are  ascribed 
to  intracellular  dehydration  secondary  to  the 
increased  concentration  of  electrolytes  in  the 
extracellular  fluid. 

This  syndrome  is  associated  with  very  dif- 
ferent conditions,  including  infantile  diar- 
rhea, brain  injury,  hyperventilation  and  di- 
abetes insipidus.  It  has  recently  become  ap- 
parent that  the  same  syndrome  may  arise 
from  the  administration  of  excessive  electro- 
lytes or  proteins  to  sick  or  premature  infants 
without  supplying  sufficient  water  to  enable 
the  sick  or  immature  kidneys  to  excrete  the 
excess.  The  load  of  solute  requiring  excre- 
tion by  the  kidneys  is  derived  almost  entirely 
from  the  electrolytes  and  proteins  in  the  diet. 
Carbohydrate  does  not  contribute  to  the  load. 

In  infants  the  proportion  of  obligatory  wa- 
ter loss  through  the  skin  is  greater  than  in 
older  children  or  adults,  because  of  the  in- 
fants’ relatively  greater  surface  area.  Con- 
centrated feeding  mixtures  based  on  plain 
cow’s  milk,  if  not  supplemented  by  an  ad- 
ditional water  intake,  provide  a smaller  mar- 
gin of  safety  against  heat  stress  and  other 
causes  of  increased  water  loss  than  does  a 
more  dilute  formula.  Feedings  prepared  at 
the  usual  concentration  of  20  calories  per 
ounce,  only  a moderate  proportion  of  the  cal- 
ories being  derived  from  carbohydrates,  are 
usually  quite  safe.  During  heat  waves  the 
osmolar  load  in  cow’s  milk  formulas  should 
be  reduced  by  dilution  and  the  addition  of 
carbohydrate,  or  the  baby  may  be  given 
carbohydrate  drinks. 


8 


J.  M.  A.  ALABAMA 


ALVEOLAR  SOFT-PART  SARCOMA  OF  THE 
GLUTEAL  REGION 

REPORT  OF  CASE  BY 
CHARLES  R.  LAFFERTY.  M.  D.i 


The  purpose  of  reporting  this  case  of  alve- 
olar soft-part  sarcoma  is  to  stress  the  impor- 
tance of  recognizing  this  rare  tumor  histologi- 
cally and  to  enable  the  clinician  to  under- 
stand its  natural  behavior. 

Histogenesis:  The  histogenesis  of  alveolar 

soft-part  sarcoma  is  not  known.  This  tumor 
is  not  traceable  to  any  well-documented  tum- 
or. Several  authors  believe  it  is  composed  of 
immature  skelleta  muscle  cells.  Christopher- 
son  et  ah’  in  1952  suggested  the  name,  alveo- 
lar soft-part  sarcoma,  because  this  tumor  is 
most  likely  to  originate  in  the  soft  tissue  of 
the  extremities.  The  neoplasm  is  always  as- 
sociated with  skeletal  muscle  or  the  musculo- 
fascial  plane.  The  tumor  is  for  the  most  part 
well  circumscribed  and  at  least  partially  en- 
capsulated. Occasionally,  there  may  be  gross 
invasion  at  one  or  more  sites,  but  usually  it 
is  easily  dissected  free  from  the  surrounding 
tissue.  The  majority  of  patients  have  been 
under  thirty  years  of  age,  and  it  is  equally 
frequent  among  males  and  females. 

In  1952  Christopherson  et  al.  made  a report 
on  twelve  cases.  The  usual  history  was  of  a 
comparatively  slow  growing  mass,  the  ma- 
jority of  which  were  asymptomatic.  In  ten  of 
the  twelve  cases  the  primary  site  was  in  one 
of  the  extremities.  There  was  one  case  from 
the  deep  lingual  muscle  and  one  from  the  ab- 
dominal-wall muscle.  Five  of  the  twelve 
patients  developed  metastatic  lesions.  Four 
of  these  have  died,  and  one  is  living  with  ex- 
tensive pulmonary  metastases  five  years  aft- 
er removal  of  the  primary  tumor.  Metastatic 
deposits  were  pulmonary  in  all  cases,  and  in 
addition,  the  brain  was  involved  in  two,  and 
the  femur,  lymph  nodes  and  subcutaneous 
tissues  in  one  instance  each.  Of  the  seven 
living  patients,  two  are  one  and  one-half 
years  or  less  post-operative,  the  other  five 
have  survived  without  recurrence  or  metas- 
tasis from  five  to  fifteen  years  after  removal 

1.  Chief,  Laboratory  Service,  Gulfport  Division, 
VA  Center,  Biloxi,  Miss. 

JULY  I960— VOL.  30,  NO.  I 


of  the  primary  tumor. 

REPORT  OF  CASE 

History:  This  twenty-three  year  old  vet- 

eran was  admitted  to  the  Biloxi  VA  Hospital 
on  21  July,  1958  because  of  an  abnormal  chest 
X-ray.  The  chest  X-ray  was  made  in  conjunc- 
tion with  an  examination  for  entrance  to  a 
school  on  19  June,  1958.  When  the  abnormal 
X-ray  findings  were  discovered,  a complete 
work-up  was  made  by  a local  physician.  The 
patient  denied  having  any  symptoms.  Sub- 
sequent X-rays  of  the  chest  revealed  multiple 
lesions  scattered  throughout  both  lungs.  Rou- 
tine laboratory  examinations,  including  tests 
for  fungi  and  tuberculosis  were  negative.  An 
intravenous  pyelogram  revealed  no  abnormal 
findings.  Because  of  the  undetermined  na- 
ture of  the  lung  lesions,  the  patient  was  ad- 
mitted to  the  VA  Hospital  at  Biloxi,  Missis- 
sippi, for  further  study.  The  patient  gave  a 
history  of  gradual,  steady  loss  of  thirty-five 
pounds  of  weight  in  the  past  two  years.  He 
denied  having  had  any  other  symptoms. 

Physical  Examination:  On  admission, 

physical  examination  revealed  a quite  poorly 
nourished  and  somewhat  poorly  developed 
young  white  male  who  was  in  no  acute  dis- 
tress but  who  did  appear  chronically  ill.  Tem- 
perature was  99°,  pulse  98  per  min.,  blood 
pressure  106/74.  He  was  mentally  alert  and 
oriented.  Examination  revealed  a rather 
poorly  developed  chest  with  bony  cage  being 
flattened  anteriorly  and  with  some  bilateral 
flaring  of  the  lower  rib  margins  anteriorly. 
Respiratory  excursions  were  equal  bilateral- 
ly but  seemed  slightly  restrictive.  Physical 
examination  of  the  lungs  was  otherwise  nor- 
mal. The  heart  and  abdomen  were  normal. 
There  was  no  edema.  No  clubbing  of  the  fin- 
gers was  present.  Small,  shotty,  non-tender, 
freely  movable  axillary  nodes  were  felt  bi- 
laterally. He  had  no  wounds. 

Laboratory  and  X-ray  Findings:  Admis- 

sion laboratory  work  revealed  a normal  hem- 
ogram. Urinalyses  were  negative.  Frog  test 

9 


SARCOMA  OF  THE  GLUTEAL  REGION 


was  negative.  Chest  X-ray  showed  a number 
of  nodular,  soft  tissue  densities  scattered  in 
both  lung  fields  but  mostly  in  the  lower  half. 
They  were  well  circumscribed  and  varied  in 
size  from  several  millimeters  to  about  one 
centimeter  in  diameter.  The  radiologist’s  im- 
pression was  multiple,  malignant  metastases 
and  that  they  were  not  inflammatory  lesions. 
Skull  X-rays  and  X-rays  of  the  pelvis  and  all 
extremities,  including  the  hands,  were  nor- 
mal. 

Course:  The  patient  had  had  no  specific 

symptoms  during  the  present  hospitalization 
and  had  been  freely  ambulatory  during  the 
entire  time.  Serial  chest  X-rays  at  first 
showed  no  discernible  changes  in  the  appear- 
ance of  the  lung  lesions,  but  the  most  recent 
film  made  on  23  Sept.,  ’58  was  thought  by  the 
radiologist  to  show  possible  beginning  calci- 
fication of  some  of  the  lesions.  Skin  tests 
with  blastomycin,  coccidioidin,  and  histoplas- 
min  were  negative.  Intermediate  PPD  tests 
were  negative.  Three  gastric  washing  cul- 
tures were  reported  negative  for  acid-fast 
bacilli.  Complement  fixation  tests  were  done 
for  a variety  of  fungi  infections,  and  they 
were  all  negative.  The  patient  was  discharged 
10-9-58  and  carried  as  a non-bed  occupancy 
patient. 

On  3 March,  1959,  he  was  examined  again 
by  his  local  physician,  and  it  was  found  that 
he  had  developed  considerable  pain  in  his 
right  hip  and  groin.  He  was  readmitted  to 
the  hospital  4 Mar.,  ’59,  where  a Vim-Silver- 
man  needle  biopsy  of  a mass  in  the  hip  pro- 
duced a result  microscopically  similar  to  met- 
astatic clear  cell  carcinoma  of  the  kidney  or 
alveolar  soft-part  sarcoma.  On  this  second 
admission  to  the  hospital  he  began  to  have 
positive  neurological  signs.  There  was  ankle 
clonus  bilaterally,  and  the  great  toe  lacked 
proprioception.  He  had  right  gluteus  medius 
weakness  with  a limp.  On  16  April,  ’59  he 
was  transferred  to  the  VA  Hospital,  New  Or- 
leans, Louisiana.  On  30  April,  ’59  a soft  tis- 
sue tumor  mass  of  the  right  gluteal  region 
with  small  bone  curettings  was  removed  from 
the  region  of  the  right  ileum.  Specimen  re- 
moved was  in  two  parts.  This  consisted  of  a 
piece  of  tissue  weighing  172  grams.  It  had  a 


yellow,  mottled  nodular  appearance  and  soft 
rod  necrotic  tissue.  The  second  specimen 
consisted  of  scrapings  from  the  right  hip  and 
ileum.  Microscopic  examination  of  the  soft 
tissue  removed  from  the  right  hip  revealed 
either  alveolar  soft-part  sarcoma  or  meta- 
static renal  cell  carcinoma.  The  curettings  of 
the  ileum  revealed  no  tumor  tissue.  X-rays 
on  16  April,  ’59  demonstrated  the  lungs  to  be 
riddled  with  metastases,  and  there  was  also 


Microscopic  Appearance  of  Metastasis  to  the 
brain. 


evidence  of  considerable  destruction  of  the 
lower  half  of  the  right  ileum  as  well  as  the 
adjacent  ischium.  On  5 May,  ’59,  the  patient 
began  deep  radiation  to  the  anterior  chest 
consisting  of  125  RS  daily.  He  was  given  con- 
tinuous radiation  until  15  May,  ’59.  As  no 
further  benefits  could  be  derived  from  thera- 
py, the  patient  was  discharged  from  New  Or- 
leans hospital  on  25  May,  ’59.  He  was  admit- 


Cell  boundaries,  abundant  cytoplasms,  and  ec- 
centrically placed  visicular  nuclei.  Note  mitosis. 


10 


J.  M.  A.  ALABAMA 


SARCOMA  OF  THE  GLUTEAL  REGION 


ted  to  Biloxi  VA  Hospital  again  on  9 July,  ’59. 
On  this  final  admission  to  Biloxi  Hospital,  the 
chief  complaint  was  weakness,  nausea,  and 
vomiting.  The  legs  were  slightly  spastic. 
There  was  some  generalized  weakness  most 
marked  on  the  right  side.  There  was  a posi- 
tive Babinski  in  the  right  foot,  as  well  as 
some  loss  of  position  sense  in  this  leg.  His 
neurological  signs  progressed,  and  he  became 
weak  and  died  on  7 Aug.,  ’59. 

SIGNIFICANT  POST-MORTEM  FINDINGS 

The  significant  autopsy  findings  are  as  fol- 
lows: The  body  was  that  of  a 24  year  old, 

fully  developed,  cachetic  white  male,  height 
5 feet  10  inches,  body  weight  120  pounds.  The 
sclera  was  white  and  clear.  The  chest  was 
somewhat  flattened,  and  the  ribs  were  promi- 
nent. The  abdomen  was  flat  and  symmetri- 
cal. The  genitalia  appeared  normal.  There 
was  some  slight  generalized  atrophy  of  the 
lower  extremities.  There  was  a post-opera- 
tive scar  10  cm.  in  length  over  the  right  poste- 
rior pelvis  as  a result  of  recent  surgery  for 
removal  of  a tumor  mass. 

The  abdominal  organs  revealed  no  evi- 
dence of  a primary  tumor  or  metastasis. 


Pseudo  alveolar  arrangements  of  cells  from  pri- 
mary site. 


The  Lungs:  On  opening  the  pleural  cavity 

it  was  noted  that  the  surface  of  both  lungs, 
particularly  the  lower  lobes,  were  studded 
with  tumor  metastases,  varying  in  diameter 
from  1/2  to  % cm.,  reddish  gray,  rather  firm, 
and  raised  above  the  lung  surface.  The  cut 
section  revealed  numerous  reddish  gray  tum- 


or nodules  with  an  average  diameter  of  1/2 
cm.  throughout  the  parenchyma  in  all  lobes. 

The  Brain:  On  removing  the  calvarium 

and  opening  the  dura,  it  was  noted  that  the 
cortical  surfaces  of  the  brain  were  flattened, 
indicating  a marked  increase  in  intracranial 
pressure.  On  the  cut  section  in  the  right  cer- 
ebral hemisphere,  there  was  a tumor  mass 
which  measured  3V2  cm.  in  diameter  and  ex- 
tended from  the  upper  portion  of  the  basal 
ganglia  and  corpus  callosum  into  the  white 
substance  of  the  cerebral  hemisphere.  The 
tumor  mass  was  grayish-red  in  color  and 
rather  soft  and  hemorrhagic.  The  primary 
site  in  the  right  gluteal  region  was  not  ex- 
plored at  the  time  of  post  mortem. 

Microscopic  Examination:  Sections  made 

from  the  tumor  removed  from  the  right  glu- 
teal region  showed  that  metastases  to  the 
lungs  and  brain  revealed  a similar  unique  his- 
tological pattern.  The  tumor  was  character- 
ized by  a pseudo  alveolar  arrangement.  The 
groups  of  cells  were  separated  by  thin  vas- 
cular septa  of  fibrous  tissue.  These  pseudo 
alveoli  were  lined  with  oval  polyhedral  cells 


-t.  .4/ 

V - 


Metastasis  to  the  brain  from  right  gluteal  region. 

of  various  sizes,  having  distinct  cell  bounda- 
ries. There  was  an  abundance  of  cytoplasm 
which  had  a granular  appearance  and  light 
eosinophilic  hue.  The  nucleus,  sometime  con- 
taining one  or  more  nucleoli,  was  placed  ec- 
centrically and  in  the  center.  Sections  stained 
for  fat  revealed  numerous  droplets  in  the 
cytoplasm  of  these  cells.  Occasional  mytotic 
figures  were  noted  throughout  the  section.  In 

1 1 


JULY  I960— VOL.  30,  NO.  I 


SARCOMA  OF  THE  GLUTEAL  REGION 


the  metastatic  lesions  there  were  large  dilat- 
ed blood  channels.  Perhaps,  the  most  strik- 
ing features  of  this  tumor  were  the  large  cells 
with  a slight  acidophilic  hue  in  pseudo  alveo- 
lar formation. 


Tumor  cells  invading  the  lungs. 


DISCUSSION 

Alveolar  soft-part  sarcoma  may  be  classi- 
fied as  a rare  tumor.  The  precise  origin  of 
this  tumor  is  not  known.  Several  authors  re- 
gard it  as  an  immature  skeletal  muscle  tum- 
or. However,  the  histology  of  this  tumor  does 
not  have  the  characteristics  of  true  skeletal 
muscle  tumor.  The  diagnosis  of  this  tumor 
has  been  a problem  to  the  pathologist,  but 
now  that  Christopherson  et  al.  have  placed 
this  tumor  in  a separate  category,  this  may  be 
of  assistance  to  the  pathologist  and  help  him 
to  differentiate  this  from  the  metastatic  carci- 
noma of  the  kidney  and  benign  and  malignant 
myoblastoma.  If  the  pathologist  will  study 
the  photo-micrographs  of  this  tumor,  it  will 
assist  him  to  differentiate  it  from  other  tum- 
ors. Also,  the  natural  behavior  places  al- 
veolar soft  tissue  sarcoma  in  a different  cate- 
gory from  benign  myoblastoma,  malignant 
myoblastoma,  and  metastatic  carcinoma.  This 
tumor  most  frequently  arises  in  the  soft-part 
of  the  extremities  and  metastasizes  to  the 
lungs,  brain,  and  bone.  The  average  dura- 
tion of  this  disease  is  five  years. 

SUMMARY 

A case  of  alveolar  soft-part  sarcoma  is  re- 
ported. The  tumor  had  its  origin  in  the  right 
gluteal  region  and  metastasized  to  the  lungs 


and  brain  with  questionable  metastasis  to  the 
pelvis.  The  tumor  was  discovered  accidental- 
ly on  a routine  examination  of  the  chest.  The 
patient  presented  no  symptoms  although  he 
had  lost  considerable  weight.  Later,  the  pri- 
mary site  was  discovered  in  the  right  gluteal 
region.  The  patient  died  about  thirteen 
months  following  discovery  of  metastases  in 
the  lungs.  The  cause  of  death  was  metastasis 
to  the  brain.  We  do  not  wish  to  add  to  the 
confusion  that  has  been  present  in  the  past  in 
diagnosing  this  tumor,  but  since  many  of  our 
cells  demonstrated  sudanophilic  droplets,  this 
may  support  the  theory  that  this  tumor  had 
its  origin  from  immature  lipoid  cells.  These 
tumors  do  not  respond  to  radiation  treatment. 
Wide  excision  of  the  primary  site  is  the  best 
therapy. 

REFERENCES 

1.  Christopherson,  W.  M.,  Foote,  F.  W.,  Jr.,  and 
Steward,  F.  W.:  Aveolar  Soft-Part  Sarcomas. 

Cancer  5;  100-111,  1952. 

THERAPY 

ANTICOAGULANTS 

Heparin  Preferred  for  Use  During  Pregnancy 

in  Order  to  Minimize  Danger  to  the  Fetus 

Anticoagulants  of  the  dicoumarin  type  are 
being  increasingly  used  in  the  treatment  of 
thrombophlebitis  and  accompanying  pul- 
monary embolism  during  pregnancy.  This 
therapy  is  not  altogether  safe.  Fetal  death 
from  hemorrhage  has  been  reported. 

In  three  cases  fetuses  died  in  utero  about 
five  weeks  after  the  start  of  anticoagulant 
therapy  with  warfarin.  The  mothers’  pro- 
thrombin time  was  carefully  controlled  and 
never  exceeded  35  seconds,  and  they  showed 
no  evidence  of  hypofibrinogenemia.  All  the 
fetuses  were  severely  macerated,  but  autopsy 
did  not  establish  the  cause  of  death. 

Since  warfarin  seems  to  have  played  at 
least  a provocative  role  in  these  cases,  the 
use  of  this  type  of  drug  in  pregnancy  should 
be  avoided.  Heparin  treatment  is  safer  at 
this  period. 

(From:  William  A.  Epstein,  Journal  of  the 
Mount  Sinai  Hospital,  World-Wide  Ab- 
stracts.) 


12 


J.  M.  A.  ALABAMA 


THE  RECOGNITION  OF  URETERAL  DAMAGE 
FOLLOWING  PELVIC  SURGERY 

HENRY  B,  TURNER,  M.  D. 


Much  has  been  written  concerning  the 
danger  of  ureteral  damage  during  pelvic 
surgery.  An  equal  amount  of  information 
has  been  disseminated  concerning  the  tech- 
nic of  ureteral  repair  following  injury.'- 
From  personal  experience  and  from  perusal 
of  the  recent  literature  it  appears  that  too 
little  has  been  said  regarding  the  recognition 
of  ureteral  injury. 

Is  it  true,  for  example,  that  the  completely 
ligated  ureter  produces  no  symptoms?  Fur- 
thermore, what  place  does  intravenous  py- 
elography have  in  the  recognition  of  ureteral 
injury?  Finally,  just  what  reliable  measures 
might  be  employed  during  and  following 
pelvic  surgery  to  aid  one  in  making  a diag- 
nosis of  ureteral  damage? 

In  an  effort  to  answer  some  of  these  ques- 
tions a study  was  made  of  all  cases  of  ureteral 
injury  encountered  on  the  gynecology  serv- 
ice of  the  City  of  Memphis  Hospitals  for  a 
15  year  period.  Information  collected  in- 
cluded incidence  of  injury,  type  of  operation, 
extent  of  pathology,  method  of  recognition, 
type  repair,  and  the  eventual  outcome  of  the 
case.  Particular  emphasis  was  placed  on  the 
method  by  which  the  correct  diagnosis  of  in- 
jury was  made. 

MATERIAL 

During  the  years  1942  through  1956,  there 
were  3,898  hysterectomies  performed  in  the 
hospital.  The  recorded  cases  of  ureteral  in- 
jury were  seven.  The  incidence  of  injury  is, 
therefore,  0.17  per  cent.  Table  1 outlines  the 


TABLE  1.  HYSTERECTOMIES.  CITY  OF  MEMPHIS 
HOSPITALS  1942-1956, 


Type  of  Hysterectomy 

Cases 

Ureteral  Injury 

Abdominal 

3182 

1 

Vaginal 

646 

0 

Wertheim 

70 

0 

3898 

7 

From  the  Division  of  Obstetrics  and  Gynecology, 
The  University  of  Tennessee  College  of  Medicine, 
and  The  City  of  Memphis  Hospitals. 

Read  before  the  Alabama  Surgical  Section, 
United  States  Section,  International  College  of 
Surgeons,  Tuscaloosa,  May  26,  1960. 


types  of  hysterectomy  and  the  occurrence  of 
injury  in  each. 

No  attempt  was  made  to  divide  the  cases 
as  to  total  versus  sub-total  hysterectomy  be- 
cause frequently  the  simpler  operation  was 
utilized  in  the  most  difficult  cases.  Of  the  7 
cases  in  which  ureteral  damage  was  sustained, 
3 involved  the  sub-total  operation.  Such 
figures,  on  a service  where  this  operation  is 
now  infrequently  employed,  would  weight 
the  evidence  unjustly  in  favor  of  total  hys- 
terectomy and  would  prove  nothing.  Con- 
trary to  the  experience  of  others,'  we  have 
no  cases  of  injury  from  radical  pelvic  sur- 
gery. In  all  probability,  we  will  have  as  our 
indications  for  this  type  surgery  are  broad- 
ened. 

OBSERVATIONS 
PREOPERATIVE  WARNINGS: 

Table  2 reveals  that  all  but  one  of  the 
cases  shared  a common  denominator — the 
pelvic  pathology  was  extensive.  Intraliga- 
mentous fibroid  nodules  of  great  size,  pelvic 
inflammatory  disease  or  large  ovarian  cysts 
were  factors  in  each  case.  All  cases  were 
considered  satisfactory  operative  risks. 

In  no  cases  were  ureteral  catheters  passed 
preoperatively.  Often  we  have  anticipated 
their  use  but  the  operator,  because  of  distor- 
tion of  the  bladder,  has  been  unable  to  cathe- 
terize  the  ureter.  Forewarned  of  a difficult 
case,  therefore,  we  would  advocate  the  plac- 
ing of  catheters  in  the  ureters  if  it  is  tech- 
nically feasible.  It  should  be  noted  that  in 
other  series'  ureteral  injury  has  been  en- 
countered as  the  result  of  inserting  cathe- 
ters. So,  this  precautionary  step  is  not  in 
itself  entirely  benign. 

TABLE  2.  OPERATIVE  FINDINGS  IN  7 CASES 
OF  URETERAL  INJURY. 

Case  Age  Operation  Pathology 

1 40  sub-total  hysterectomy,  large  intraligamentous 

bilateral  salpingo-  myoma 

oophorectomy 

2 28  total  hysterectomy,  bi-  large  myoma  in  recto- 

lateral  salpingectomy  vaginal  septum 
and  left  oophorectomy 
(previous  right  oopho- 
rectomy) 


JULY  I960— VOL.  30,  NO.  I 


13 


PELVIC  SURGERY 


3 

38 

“extrafascial”  hysterec- 

carcinoma-in-situ o£ 

tomy 

cervix 

4 

88 

total  hysterectomy,  bi- 

extensive pelvic  in- 

lateral salpingo-oopho- 
rectomy 

flammatory  disease 

5 

40 

total  hysterectomy,  bi- 

intraligamentous my- 

lateral salpingo-oopho- 
rectomy 

oma,  liomyosarcoma 

G 

41 

sub-total  hysterectomy. 

large  myoma  with  ova- 

bilateral .salpingo- 

rian  cysts,  pelvic  in- 

oophoi'ectomy 

flammatory  disease 

7 

44 

sub-total  hysterectomy. 

myoma  with  cystade- 

bilateral  salpingo- 

noma  and  many  adhe- 

oophorectomy 

sions 

OPERATIVE  WARNINGS: 

In  4 of  the  7 cases  the  operator  recognized 
ureteral  damage  immediately.  In  2 others, 
damage  was  feared  and  the  diagnosis  proven 
during  the  first  few  postoperative  days.  In 
only  one  case  was  there  a failure  to  make 
the  correct  diagnosis  and,  unfortunately,  this 
resulted  in  the  only  death  directly  due  to 
ureteral  injury. 

The  warning  issued  prior  to  surgery  is  re- 
iterated at  the  operating  table — beware  of 
ureteral  injury  when  dealing  with  massive 
pelvic  pathology  and  especially  tumors  be- 
tween the  layers  of  the  broad  ligament  and 
deep  within  the  cul-de-sac. 

Also  a second  lesson  is  apparent:  Don’t 
depart  from  recognized  procedures  in  an 
overzealous  attempt  “to  save”  the  patient 
from  cancer  Case  3 represents  an  attempt 
to  “go  just  a little  wider”  on  the  parametrial 
dissection  because  of  a preoperative  diag- 
nosis of  carcinoma-in-situ  of  the  cervix.  The 
right  ureter  was  severed  near  the  lateral 
aspect  of  the  cervix  with  ligation  of  the  proxi- 
mal end.  The  distal  end,  near  the  bladder, 
was  patent.  The  postoperative  course,  there- 
fore, was  uneventful,  until  the  indwelling 
bladder  catheter  was  removed  on  the  second 
day.  The  abdomen  thereafter  became  dis- 
tended; x-ray  films  suggested  paralytic  ileus 
and  too  late  was  urinary  extravasation  given 
serious  consideration.  The  patient  died  on 
the  12th  postoperative  day.  Postmortem  ex- 
amination revealed  5000  c.  c.  of  urine  in  the 
abdominal  cavity  with  associated  compres- 
sion atelectasis  of  the  lungs. 

POSTOPERATIVE  CONSIDERATIONS: 

If  the  diagnosis  of  ureteral  injury  is  not 
made  at  the  time  of  surgery,  the  situation 


worsens  for  both  patient  and  physician.  In 
our  3 such  cases  one  died  of  unrecognized 
intra-abdominal  urinary  extravasation  as 
outlined  above. 

The  second  case  involved  a severed  right 
ureter  and  ligation  of  the  left.  Both  injuries 
occurred  near  the  cervix.  Diagnosis  was 
made  on  the  fourth  postoperative  day  by  di- 
rect cystoscopy  and  attempts  to  pass  ureteral 
catheters.  By  this  time  the  abdomen  was 
distended,  shifting  dullness  was  noted  and 
the  pulse  was  quite  rapid.  Treatment  con- 
sisted of  right  ureterocystostomy  and  deliga- 
tion of  the  left  ureter.  After  suffering  much 
morbidity,  the  patient  was  discharged  on 
the  47th  postoperative  day.  She  required 
prolonged  care  in  the  Urology  Out-Patient 
Clinic. 

The  third  case  of  unrecognized  ureteral  in- 
jury was  that  of  a 46  year  old  patient  with  a 
diagnosis  of  liomyosarcoma  of  the  uterus. 
There  was  a large  intraligamentous  tumor 
mass  on  the  left.  Damage  following  total 
hysterectomy  and  bilateral  salpingo-oopho- 
rectomy  consisted  of  ligation  of  the  left  ureter 
and  kinking  of  the  right  ureter  by  ligature. 
There  was  no  pain  referable  to  the  urinary 
tract.  Intravenous  pyelography  on  the  sec- 
ond day  revealed  a nephogram  only  on  the 
right  (partial  obstruction)  and  an  enlarged 
kidney  shadow  on  the  left  but  no  media 
(complete  obstruction).  Because  of  the  pa- 
tient’s poor  general  condition,  in  the  face  of 
extensive  pelvic  malignancy,  a permanent 
nephrostomy  was  performed  on  the  left. 
Death  occurred  10  months  later  from  recur- 
rent sarcoma. 

The  important  postoperative  considerations 
would  appear  to  be  these:  1.  Keep  the  possi- 
bility of  ureteral  injury  in  mind,  particularly 
if  the  pelvic  pathology  has  been  extensive. 
2.  Don’t  be  fooled  by  abdominal  distention — ■ 
it  could  be  urine  rather  than  gas!  3.  Initiate 
diagnostic  procedures  early  if  the  possibility 
of  ureteral  injury  exists.  Not  entirely  fa- 
cetiously speaking,  the  accurate  postopera- 
tive measurement  of  urinary  output  by 
nurses  is  fast  becoming  a lost  art  and  should 
not  be  relied  on  in  many  hospitals. 


14 


J.  M.  A.  ALABAMA 


PELVIC  SURGERY 


TYPES  OF  REPAIR 

A discussion  of  various  surgical  technics  is 
not  the  purpose  of  this  communication.  In 
reviewing  Table  4,  however,  it  is  found  that 
5 types  of  repair  were  utilized.  Arranged  in 
ascending  order  of  technical  difficulty,  these 
consisted  of:  deligation;  ligation  of  proximal 
ureter  with  intentional  sacrifice  of  one  kid- 
ney; nephrostomy;  end  to  end  anastomosis, 
and  ureterocystostomy.  Parenthetically,  the 
patient  experiencing  the  least  postoperative 
morbidity  (Case  No.  1)  was  treated  by  in- 
tentional ligation  of  the  severely  damaged 
ureter.  She  had  no  pain  referable  to  the 
sacrificed  kidney  and  was  discharged  on  the 
18th  postoperative  day.  This  is  the  shortest 
period  of  hospitalization  in  the  series. 

DIAGNOSTIC  PROCEDURES  AND  FINDINGS 

Table  3 lists  the  site  and  extent  of  damage 
and  Table  4 outlines  the  diagnostic  proce- 
dures and  type  repair  in  each  of  the  7 cases. 

TABLE  3.  SITE  OF  INJURY  AND  EXTENT 
OF  DAMAGE 


Case 

Site  of  Injury 

Damage 

1 

mid-pelvis 

several  inches  of  ureter 
destroyed 

2 

bilateral,  near 
cervix 

right  severed; 
left  ligated 

3 

near  cervix 

right  severed 

4 

pelvic  brim 

left  severed  and  ligated 

5 

near  bladder 

kinking  of  right  ureter; 
ligation  of  left 

6 

near  cervix 

severed  left 

7 

pelvic  brim 

ligated  left 

TABLE  4.  DIAGNOSTIC  MEASURES  AND  TYPE 
REPAIR  OF  URETERAL  INJURY 

Diagnostic 


Case 

Measures 

Type  Repair 

1 

recognized  at  sur- 
gery 

unable  to  anastomose  end  to 
end.  After  proving  good  right 
kidney  and  ureter,  left  ureter 
was  ligated. 

2 

cystosccKpy  with  at- 
tempt to  pass  cathe- 
ters 

right  ureterocystostomy,  left 
deligation 

3 

flat  plate  of  abdo- 
men suggested  ileus 

none 

4 

recognized  at  sur- 
gery 

end  to  end  repair  over 
polyethylene  tube 

5 

I.  V.  P.  = nephro- 
gram on  right;  en- 
larged kidney  shad- 
ow on  left 

nephrostomy;  dilatation 
of  right  ureter 

6 

recognized  at  sur- 
gery 

end  to  end  repair  over 
polyethylene  tube 

7 

recognized  at  sur- 
gery 

end  to  end  repair  over 
polyethylene  tube 

Because!  damage  was  recognized  at  the 
time  of  surgery  in  4 cases  and  never  diag- 
nosed in  another,  only  2 cases  remain  in 
which  diagnostic  procedures  may  be  evalu- 
ated. 

In  case  number  2 the  diagnosis  was  clari- 
fied quite  expeditiously  by  cystoscopy  with 
attempt  to  pass  ureteral  catheters.  In  case 
number  5,  intravenous  pyelography  revealed 
media  in  the  right  kidney  24  hours  following 
surgery  but  none  in  the  incompletely  ligated 
right  ureter.  On  the  left  where  ligation  was 
complete,  only  a large  renal  shadow  was 
visible.  Such  findings  are  said  to  be  typical. 
Renal  function,  however,  as  reflected  by  in- 
travenous pyelography  following  ureteral  in- 
jury is  variable. 

At  the  present  time,  we  believe  that  cys- 
toscopic  passage  of  ureteral  catheters  is  the 
most  direct  and  trustworthy  technic  to  diag- 
nose ureteral  damage.  Intraveno  is  pyelog- 
raphy, if  employed,  is  of  value  only  in  a neg- 
ative way  when  kidneys  and  ureters  are  clear- 
ly outlined.  Superior  to  both  technics  is  the 
alert  operator  who  is  aware  of  possible  ure- 
teral damage  and  recognizes  this  complica- 
tion at  the  operating  table. 

SUMMARY 

At  the  City  of  Memphis  Hospitals,  ureteral 
injury  following  hysterectomy  occurred  in 
0.17  per  cent  of  cases  over  a 15  year  period. 
Extensive  pelvic  pathology  was  present  in 
all  but  one  case.  There  was  one  death  attrib- 
uted to  ureteral  damage  per  se.  In  the  ma- 
jority of  cases,  injury  was  recognized  at  sur- 
gery and  corrected  immediately.  A variety 
of  technics  were  employed  in  repair  depend- 
ing upon  the  location  and  extent  of  the  ure- 
teral damage. 

Of  the  diagnostic  tools,  an  alert  mind  and 
an  awareness  of  the  type  case  in  which  ure- 
teral injury  is  most  likely  to  be  encountered 
is  the  best.  Secondly,  is  a willingness  to 
search  for,  and  an  ability  to  recognize  injury 
at  the  time  of  surgery.  In  the  postoperative 
period,  the  retrograde  passage  of  ureteral 
catheters  is  the  most  reliable  diagnostic  aid. 
Intravenous  pyelography  is  of  use  but  the 
results  may  be  inconclusive. 


JULY  I960— VOL.  30,  NO.  I 


15 


PELVIC  SURGERY 


REFERENCES 

1.  Everett,  H.  S.  and  Mattingly,  R.  F.:  Urinary 
Tract  Injuries  Resulting  From  Pelvic  Surgery. 
Am.  J.  Obst.  & Gynec.  71:  502,  1956. 

2.  Benson,  R.  C.  and  Hinman,  F.  Jr.:  Urinary 
Tract  Injuries  in  Obstetrics  and  Gynecology.  Am. 
J.  Obst.  & Gynec.  70:  467,  1955. 

3.  Brown,  W.  E.  and  Sutherland,  C.  G.:  The 

Repair  of  Ureteral  Injuries.  Am.  J.  Obst.  & Gynec. 
77:  862,  1959. 


LEGAL  MEDICINE 

INDUSTRIAL  NOISE 

Recent  Compensation  Legislation  on  Hearing 

Loss  in  New  York,  Wisconsin  and  Missouri. 

Although  medical  literature  on  industrial 
noise  dates  back  to  the  1880s,  many  consider 
this  a problem  of  recent  origin.  Concern  for 
the  problem,  in  fact,  is  comparatively  recent, 
stemming  from  court  decisions  in  Wisconsin 
and  New  York.  Both  those  states  as  well  as 
Missouri  have  enacted  laws  dealing  with 
workmen’s  compensation  for  loss  of  hearing 
due  to  industrial  noise.  The  court  decisions 
held  that  an  employee  is  entitled  to  a sub- 
stantial sum  as  compensation  for  partial 
hearing  loss  due  to  noise  in  employment  as  a 
scheduled  permanent  disability,  although  he 
continued  at  work  without  loss  of  wage. 

One  study  indicated  that  25  percent  of  ap- 
plicants for  industrial  jobs  had  a hearing  loss. 
Many  places  of  employment  have  noise  levels 
such  that  rightly  or  wrongly,  it  could  be 
claimed  that  they  contributed  to  hearing  loss. 

In  Wisconsin,  legislation  accepted  the  prin- 
ciple that  compensation  should  not  be  pay- 
able while  the  employee  continued  in  his 
noisy  employment  unless  he  suffered  a wage 
loss  because  of  transfer  by  his  employer.  In 
the  absence  of  such  provision  a claimanti 
would  have  been  able  to  collect  relatively 
large  sums  while  continuing  in  employment 
at  full  wage.  In  other  cases  not  covered  by 
this  provision,  no  claim  for  compensation 
could  be  filed  until  six  consecutive  months 
away  from  noisy  employment.  The  time  of 
injury  was  redefined  to  refer  to  transfer  to 
non-noisy  work,  retirement,  termination  of 
employment  or  layoff  for  a year. 

New  York’s  law  has  two  major  features. 


One  is  acceptance  of  the  principle  that  there 
must  be  a six-month  separation  from  the  last 
employment  in  which  there  was  at  any  time 
exposure  to  noise  before  compensation  is 
payable.  The  last  date  of  the  period  of  sepa- 
ration is  to  be  considered  the  date  of  disable- 
ment. 

A second  major  feature,  disturbing  to  both 
industry  and  labor,  is  a provision  that  an  em- 
ployer may  give  notice  to  prior  employers  of 
hearing  losses  shown  on  pre-employment 
examination  of  workers  changing  jobs;  in  the 
event  of  a subsequent  claim  and  award,  re- 
quest for  a contribution  from  the  prior  em- 
ployer may  be  made.  A copy  of  the  notice 
goes  to  the  worker  as  well  as  the  past  em- 
ployer. 

The  1959  Missouri  loss-of-hearing  amend- 
ment also  has  a six-month  waiting  period. 
Loss  of  hearing  due  to  industrial  noise  for 
compensation  purposes  is  limited  to  the 
speech  frequencies,  500,  1000  and  2000  cycles. 
It  further  provides  that  a loss  averaging  fif- 
teen decibels  or  less  does  not  constitute  com- 
pensable hearing  disability.  Losses  averag- 
ing 82  decibels  or  more  constitute  100-per- 
cent compensable  hearing  loss. 

The  lowest  measured  losses  in  the  three 
frequencies  are  added  together  and  divided 
by  three  to  determine  the  average  decibel 
loss.  For  every  decibel  of  loss  exceeding 
15  db.  an  allowance  of  1.5  percent  is  made; 
100  percent  is  reached  at  82  db. 

Loss  in  the  better  ear  is  weighted  in  a 
proportion  suggested  by  the  Subcommittee 
on  Noise  of  the  American  Academy  of  Oph- 
thalmology and  Otolaryngology.  Loss  in  the 
better  ear  is  multiplied  by  six  and  added  to 
the  loss  in  the  poorer  ear,  and  the  sum  is 
divided  by  six. 

To  allow  for  presbycusis  half  a decibel  is 
deducted  from  the  total  average  decibel  loss 
for  each  year  of  age  over  40  at  the  time  of 
the  last  exposure  to  the  industrial  noise.  In 
Missouri  the  last  employer  is  liable  for  the 
entire  occupational  deafness  to  which  the 
employment  has  contributed,  but  the  em- 
ployer is  not  liable  for  previous  loss  estab- 
lished by  competent  evidence. 


16 


J.  M.  A.  ALABAMA 


PHYSICIANS  FOR  A GROWING  AMERICA 


ROBERT  C.  BERSON,  M.  D. 


When  I reported  to  the  annual  meeting  of 
this  Association  three  years  ago  the  Medical 
Center  faced  a crisis.  Not  only  were  its 
needs  for  room  for  expansion,  facilities  for 
research  and  housing,  for  an  increased  num- 
ber of  nursing  students  desperate;  but  also  a 
large  parcel  of  adjoining  land  was  available 
for  purchase  on  very  favorable  terms  and 
half  the  cost  of  a research  building  was  avail- 
able in  the  form  of  a grant  from  the  National 
Institutes  of  Health.  Before  getting  into  the 
subject  matter  indicated  by  the  title  which 
appears  in  your  program  I want  to  give  you 
a progress  report  on  those  matters. 

Thanks  to  the  strong  support  of  the  Medi- 
cal Center  Advisory  Board,  the  Trustees  and 
President  of  the  University,  the  members  of 
this  Association,  the  Legislature,  the  Gov- 
ernor, and  a large  majority  of  the  voters  of 
the  state,  funds  to  meet  the  crisis  of  1957 
were  provided  through  a bond  issue  of  four 
and  one  half  million  dollars.  Since  that 
time: 

a)  The  land  has  been  purchased  from  the 
Housing  Authority. 

b)  The  Research  Building,  made  possible 
by  this  Bond  Issue  and  a matching  grant  from 
the  NIH,  has  been  completed  and  largely  oc- 
cupied. 

c)  A Hill-Burton  grant  for  the  construction 
of  the  University  Hospital  School  of  Nursing 
Residence  has  been  approved  in  the  amount 
of  $1,250,000.  Construction  on  this  building 
should  begin  this  year. 

In  addition: 

d)  One  block  of  the  land  has  been  sold  to 
the  Children’s  Hospital  of  Birmingham  and 
on  it  they  are  constructing  their  new  hospital. 

e)  Through  the  generous  donation  of  $100,- 
000  by  Mr.  and  Mrs.  J.  S.  Smolian,  we  were 
able  to  obtain  a Hill-Burton  grant  of  almost 
$200,000  for  a Psychiatric  Clinic  which  should 
be  completed  in  the  summer  of  1960. 


Read  before  the  Association  in  Annual  Session, 
Mobile,  April  21,  1960. 


f)  The  State  Armory  Commission  has  be- 
gun construction  of  a building  to  serve  as  a 
combination  Armory-Gymnasium-Auditori- 
um.  Military  use  of  this  building  will  have 
priority  but  in  peacetime  this  will  be  very 
limited  and  the  University  will  control  its 
use  at  all  other  times.  This  building  should 
be  completed  in  the  summer  of  1960. 

g)  A loan  under  the  College  Housing  Pro- 
gram has  been  approved  in  the  amount  of 
$1,500,000  for  the  construction  of  128  apart- 
ments for  married  students,  interns  and  resi- 
dents. Construction  of  this  building  should 
begin  within  a few  months. 

More  recently  Mr.  and  Mrs.  Frank  E.  Spain 
have  pledged  the  donation,  over  a period  of 
years,  of  securities  sufficient  to  make  up 
$500,000  toward  the  construction  of  a Re- 
habilitation Center,  contingent  upon  our  get- 
ting Federal  funds  in  the  amount  of  $1,000,- 
000.  The  prospects  for  such  Federal  funds 
are  bright  and  this  should  make  it  possible  to 
create  one  of  the  very  finest  programs  in  the 
tremendously  promising  field  of  rehabilitat- 
ing the  handicapped. 

Most  recently  the  voters  of  Alabama  gave 
overwhelming  support  to  a bond  issue  of 
$3,000,000  for  the  construction  of  a 100-bed 
Psychiatric  Unit  which  will  be  operated  as  a 
part  of  University  Hospital  and  Hillman 
Clinic  for  the  intensive  study  and  treatment 
of  a considerable  number  of  patients  and, 
more  importantly,  to  provide  a suitable  set- 
ting for  the  education  of  all  sorts  of  workers 
in  the  field  of  Mental  Health. 

So  there  has  been  some  progress.  What 
does  the  future  hold? 

Late  in  the  year  1958,  the  Surgeon  General 
of  the  Public  Health  Service  established  a 
consultant  group  on  Medical  Education  to 
whom  he  posed  the  question,  “How  shall  the 
nation  be  supplied  with  adequate  numbers  of 
well-qualified  physicians?”  Twenty-two  very 
distinguished  people  served  on  this  group  of 
consultants,  including  a member  of  the 
Board  of  Trustees  and  a member  of  the  staff 


JULY  I960— VOL.  30,  NO.  I 


17 


PHYSICIANS  FOR  A GROWING  AMERICA 


of  the  AMA,  the  Presidents  of  two  colleges, 
three  people  from  the  American  Hospital 
Association,  and  people  from  the  American 
Dental  Association,  the  National  League  for 
Nursing,  the  Association  of  American  Medi- 
cal Colleges,  the  Southern  Regional  Educa- 
tion Board,  the  Western  Interstate  Commis- 
sion for  Higher  Education,  and  able  people 
from  three  medical  schools.  They  had  the  as- 
sistance of  a capable  staff  of  full-time  work- 
ers and  made  a serious  study  of  many  rele- 
vant factors,  publishing  their  findings  under 
the  title  “PHYSICIANS  FOR  A GROWING 
AMERICA”. 

The  consultant  group  came  to  the  conclu- 
sion that  “the  maintenance  of  the  present 
ratio  of  physicians  to  population  is  a mini- 
mum essential  to  protect  the  health  of  the 
people  of  the  United  States”.  To  achieve 
this  “minimum  essential”  the  consultant 
group  concluded  that  it  would  be  necessary 
for  the  number  of  physicians  graduated  an- 
nually to  be  increased  by  approximately 
50%  by  1975,  and  that  to  accomplish  this  50% 
expansion,  not  only  would  the  existing 
schools  have  to  expand  considerably,  but  it 
would  also  be  necessary  to  establish  approxi- 
mately 20  entirely  new  schools  of  medicine 
in  this  country. 

In  my  opinion  this  excellent  monograph 
warrants  the  thoughtful  study  of  every  mem- 
ber of  this  association;  it  deals  with  the  future 
of  the  profession  on  a national  scale. 

I propose,  in  the  time  available,  to  address 
my  remarks  to  the  application  of  the  same 
trends  and  factors  to  our  own  state  of  Ala- 
bama and  to  suggest  to  you  steps  that  I think 
should  be  taken  as  we  look  to  the  future  of 
our  profession. 

A decade  and  a half  ago  Alabama  took  the 
fundamentally  important  step  of  expanding 
its  two  year  medical  school  to  a four  year 
basis  and  expanding  its  enrollment.  If  this 
step  had  not  been  taken,  a considerable  num- 
ber of  Alabama  residents  would  have  had  a 
hard  time  getting  an  opportunity  to  study 
medicine,  and  the  supply  of  physicians  in  the 
state  would  surely  be  far  smaller  than  it  is. 
Even  with  the  medical  school  graduating 


about  80  physicians  a year  we  now  have  only 
about  half  as  many  physicians  per  unit  of 
population  as  the  average  for  the  country  as 
a whole  and  the  only  two  states  with  a small- 
er supply  are  states  which  are  losing  total 
population.  For  the  country  as  a whole 
there  are  132  physicians  per  100,000  people 
and  in  Alabama  only  72  per  100,000. 

When  we  turn  to  the  consideration  of 
trends  in  our  state  which  will  have  an  im- 
portant bearing  on  the  demand  for  physi- 
cians, the  first  one  is  that  we  are  not  experi- 
encing the  sort  of  “population  explosion” 
that  is  going  on  in  some  parts  of  the  country. 
In  fact,  although  our  total  population  in- 
creased by  about  3.2%  in  the  last  decade,  the 
population  of  the  country  as  a whole  in- 
creased so  much  that  we  are  likely  to  lose 
one  seat  in  the  Congress  of  the  United  States. 
The  best  estimates  available  indicate  that  the 
total  population  of  Alabama  will  increase  by 
about  6%  during  the  next  decade. 

A closer  look  at  what  is  going  on  in  Ala- 
bama reveals  that  there  has  been  a substan- 
tial shift  in  population  from  rural  to  urban 
areas.  Every  city  of  10,000  or  more  has 
grown  rapidly  in  the  last  decade  and  there 
is  every  indication  that  this  growth  will  con- 
tinue. Correspondingly  most  rural  areas 
have  been  losing  population  and  seem  certain 
to  continue  to  do  so. 

Accompanying  this  move  to  the  city,  our 
people  are  shifting  from  farming  as  an  oc- 
cupancy to  various  non-farm  jobs,  mostly  in 
industry,  so  that  it  is  estimated  that  a ma- 
jority are  now  engaged  in  non-farm  occupa- 
tions and  most  of  these  live  in  or  very  near 
cities.  And  accompanying  both  of  these 
trends  has  been  a rising  per  capita  income. 
In  Alabama  the  per  capita  income  has  risen 
almost  twice  as  fast  as  that  of  the  country 
as  a whole  in  the  last  decade,  and  it  is  esti- 
mated that  by  1975  it  will  reach  the  national 
average. 

So  it  seems  certain  that  by  1975  the  vast 
majority  of  our  fellow  Alabamians  will  be 
employed  by  industry,  earning  as  much  as 
the  national  average,  and  living  in  or  near 
cities  large  or  small. 


18 


J.  M.  A.  ALABAMA 


PHYSICIANS  FOR  A GROWING  AMERICA 


I believe  the  conclusion  is  unavoidable  that 
the  people  of  Alabama  will  demand  approxi- 
mately as  much  medical  care  as  the  people 
of  other  states  by  1975  and  will  have  the 
ability  to  pay  for  it. 

To  meet  this  coming  demand  for  something 
like  twice  as  much  medical  care  it  is  obvious 
that  there  must  be  a marked  expansion  of 
enrollment  in  medical  school.  Regardless  of 
whether  this  expansion  takes  place  in  the  ex- 
isting program  or  through  the  development 
of  a second  medical  school,  it  will  be  dis- 
astrous unless  it  is  based  on  an  adequate  sup- 
ply of  well  qualified  students  and  a sound 
and  stable  educational  program.  For  this 
reason  I propose  to  spend  the  rest  of  the  time 
available  telling  you  something  of  the  pres- 
ent supply  of  students,  and  the  present  edu- 
cational program,  what  we  are  trying  to  do 
to  improve  both,  and  to  suggest  some  ways 
in  which  the  members  of  this  Association 
can  be  helpful  with  both. 

In  the  country  as  a whole  there  continues 
to  be  a decline  both  in  the  number  of  stu- 
dents applying  to  medical  schools  and  the 
quality  of  their  academic  performance  in 
college.  There  were  15,918  applicants  for  the 
class  entering  in  1956,  15,791  in  1957  and  only 
15,170  in  1958.  By  1958  there  were  8,030 
places  in  the  first  year  classes  of  the  medical 
schools  of  this  country,  so  there  were  only 
1.8  applicants  for  each  place  including  a good 
many  students  obviously  not  qualified  for  any 
advanced  study.  Every  medical  school  se- 
lects those  with  the  best  academic  records  in 
college,  but  in  the  class  entering  all  medical 
schools  in  1957  only  18%  had  A averages, 
66%  had  B averages  and  16%  had  C averages. 
This  is  a drastic  decline  in  quality  since  1950 
when  40%  of  the  class  entering  all  medical 
schools  had  A averages  and  only  43%  had  B 
averages. 

In  the  Medical  College  of  Alabama  our  re- 
cent experience  has  been  somewhat  more 
favorable  than  that  for  the  country  as  a 
whole.  We  had  311  applicants  for  the  class 
entering  in  1957,  329  for  1958  and  407  for  1959. 
But  their  academic  performance  in  college 
was  discouraging.  For  example,  in  the  class 


entering  in  1959,  only  15%  had  A averages, 
75%  had  B averages  and  10%  had  C averages. 
We  all  know  that  it  doesn’t  take  a genius  to 
study  and  be  effective  in  medicine,  but  it 
does  take  diligence  and  a moderate  amount 
of  native  intelligence,  and  the  grading  system 
of  most  of  our  colleges  is  so  lenient  that  these 
characteristics  will  usually  produce  a good 
academic  record. 

We  believe  that  this  mildly  favorable  trend 
in  our  applicants  is  partly  due  to  the  fact 
that  since  1957  we  have  been  accepting  ap- 
plications from  out  of  state  students,  although 
only  a very  few  have  actually  been  admitted. 
Other  factors  which  may  have  helped  are 
the  fact  that  the  school  is  fairly  young  and 
becoming  more  favorably  known,  and  some 
students  and  faculty  members  have  made  a 
conscious  effort  to  encourage  good  students 
in  several  of  the  colleges  in  the  state. 

Many  factors  influence  the  decision  of  a 
young  man  or  woman  to  prepare  himself  for 
and  enter  the  study  of  medicine.  On  a na- 
tional scale  it  seems  certain  that  competi- 
tion from  other  fields  for  talented  young 
people  is  a major  factor.  Not  only  can  a good 
college  student  easily  step  into  a job  good 
enough  for  him  to  begin  to  support  a family 
and  be  independent,  but  also  advanced  study 
in  other  fields  has  caught  the  imagination  of 
many  young  people.  A good  college  student 
can  easily  pursue  graduate  study  in  chem- 
istry, physics,  mathematics  or  most  of  the 
social  sciences  fully  supported  by  a scholar- 
ship or  fellowship  that  will  cover  his  tuition 
and  provide  for  a modest  living.  And  at  the 
completion  of  this  graduate  study  he  can  be 
confident  of  stable  employment  with  a fairly 
good  standard  of  living.  Throughout  the 
fifties  the  number  of  PhD  degrees  awarded 
in  the  physical  and  social  sciences  has  risen 
in  direct  proportion  to  the  decline  in  the 
number  of  applicants  for  medical  school. 

I think  the  members  of  this  Association 
should  be  aware  of  the  fact  that  concern  at 
the  national  level  over  the  need  for  more  and 
better  applicants  to  medical  schools  has  led 
to  serious  discussion  of  large  programs  of 
fellowships  or  scholarships  that  would  pro- 


JULY  I960— VOL.  30.  NO.  I 


19 


PHYSICIANS  FOR  A GROWING  AMERICA 


vide  approximately  as  much  financial  sup- 
port for  the  study  of  medicine  as  for  the 
graduate  study  of  some  other  disciplines.  It 
is  too  early  to  tell  whether  these  discussions 
will  lead  to  the  implementation  of  such  pro- 
grams. It  also  seems  logical  for  the  members 
of  this  Association  to  give  the  most  careful 
consideration  to  the  wisdom  of  developing 
scholarship  or  loan  funds  by  the  medical 
profession  of  this  state,  as  well  as  possible 
modification  of  the  modest  program  already 
administered  by  the  State  Board  of  Health. 

In  my  opinion  active  encouragement  and 
thoughtful  counseling  of  able  young  people 
by  the  members  of  this  Association  could  be 
much  more  important  than  any  form  of  fi- 
nancial aid.  A surprising  number  of  young 
people  make  their  career  decision  while  they 
are  still  in  high  school.  The  faculty  of  the 
medical  school  has  great  difficulty  in  getting 
to  know  many  young  people  of  high  school 
age  well  enough  to  give  them  sound  advice, 
but  it  seems  likely  that  every  talented  high 
school  student  is  known  personally  by  some 
member  of  this  Association.  ' It  could  be 
greatly  encouraging  to  them  if  they  could 
be  told  that  there  are  great  satisfactions  in 
the  study  as  well  as  the  practice  of  medicine, 
that  the  study  and  training  are  pleasant  and 
stimulating  on  a day  to  day  basis,  as  well  as 
in  their  long-range  benefits,  that  the  study 
and  work  required  are  easily  managed  once 
the  right  habits  are  formed  and  that  a vast 
number  of  physicians  have  found  ways  to 
make  ends  meet  during  the  period  of  their 
education  without  heavy  subsidy  from  their 
families.  It  would  also  help  them  if  they 
could  be  told  by  their  family  physician  that 
they  would  be  well  advised  to  develop  sound 
habits  of  study  and  an  appreciation  of  knowl- 
edge for  its  own  sake  because  if  they  do  this 
and  have  normal  intelligence  they  will  be  al- 
most certain  to  make  an  acceptable  showing 
in  college  and  find  the  work  of  medical  school 
fairly  easy. 

Even  with  an  adequate  supply  of  well 
qualified  students  expansion  of  enrollment 
would  be  disastrous  for  the  health  of  the 
general  public  unless  it  is  based  on  a sound 
and  stable  educational  program.  Our  pro- 


gram has  a good  many  strong  points,  and  it  is 
improving,  but  the  progress  is  slow.  In  my 
opinion  neither  the  faculty,  the  members  of 
this  Association  nor  the  people  of  Alabama 
can  be  content  with  slow  progress  in  the 
immediate  future.  Not  only  must  we  antici- 
pate that  there  will  be  expansion  of  enroll- 
ment in  the  existing  program  or  the  develop- 
ment of  another  medical  school,  but  also  it 
is  certain  that  a number  of  new  medical 
schools  will  be  developed  in  other  states. 
Already  the  Association  of  American  Medical 
Colleges  has  had  inquiries  from  26  universi- 
ties which  have  some  interest  in  developing 
medical  schools.  And  we  know  from  what 
has  happened  in  Mississippi,  Florida,  Ken- 
tucky, Georgia,  and  West  Virginia  that  new 
or  rejuvenated  schools  offer  our  best  people 
positions  that  make  excellent  provisions  for 
salary,  facilities  and  programs.  If  we  do  not 
make  rapid  progress  at  bringing  our  educa- 
tional program  up  to  full  strength,  we  can 
be  certain  that  the  competition  of  other  medi- 
cal schools  will  hurt  us  badly. 

Instead  of  cataloguing  all  the  strengths  and 
weaknesses  of  the  present  program  I want  to 
emphasize  two  steps  that  can  greatly  im- 
prove the  program.  Both  of  them  seem  of 
direct  importance  to  the  members  of  this 
Association,  and  I believe  that  the  strong 
support  of  this  Association  would  make  it 
possible  to  take  both  of  them  at  an  early  date. 

The  first  of  these  steps  would  be  to  put  the 
University  Hospital  in  a position  to  serve  as 
a “hospital  of  last  resort”  for  patients  and 
physicians  throughout  the  state  regardless 
of  their  ability  to  pay.  This  would  require 
an  appropriation  from  the  General  Funds  of 
the  State  for  the  admission  of  referred  indi- 
gent patients  from  each  county  on  a basis  of 
population.  To  be  of  substantial  help  to 
physicians  and  patients  throughout  the  State, 
as  well  as  to  the  educational  program,  this 
appropriation  should  be  of  the  general  order 
of  three  million  dollars  a year.  Considered 
in  isolation  this  is  a large  figure,  but  it  would 
not  be  a very  large  burden  on  the  total  re- 
sources of  this  great  state.  Such  programs 
are  already  in  existence  in  a great  many 
states  in  this  country  including  several  of 


20 


J.  M.  A.  ALABAMA 


PHYSICIANS  FOR  A GROWING  AMERICA 


our  close  neighbors. 

The  benefit  of  such  a program  to  the  sick 
poor  throughout  the  State  are,  I think,  ob- 
vious. I want  to  emphasize  the  fact  that  such 
a program  would  go  far  to  correct  the  largest 
weakness  of  the  educational  program  of  the 
medical  college.  Patients  and  their  problems 
are  the  subject  matter  of  medicine,  so  the 
teaching  hospital  is  the  setting  for  all  the 
clinical  instruction  in  medicine  as  well  as  the 
training  of  interns  and  residents.  At  the 
present  time  our  teaching  hospital  is  an  ex- 
tremely poor  setting  for  this  educational 
process.  The  fact  that  the  local  indigent  pa- 
tients are  inadequately  financed  has  made  it 
necessary  for  the  hospital  to  carry  too  high 
a census  of  paying  patients,  few  of  whom 
fit  well  into  the  educational  program,  and 
it  still  has  such  serious  financial  problems 
that  it  cannot  go  forward  with  many  of  the 
things  a teaching  hospital  should  do,  and  just 
avoiding  bankruptcy  makes  fearful  inroads 
on  the  time  and  energy  of  the  senior  faculty. 

When  we  are  in  a position  to  have  stable 
financial  support  for  accepting  patients  re- 
ferred by  physicians  throughout  the  State, 
primarily  because  the  patient  will  fit  into 
and  benefit  from  the  program  of  the  teaching 
hospital,  the  opportunity  of  every  medical 
student  to  learn  medicine  will  be  vastly  im- 
proved. 

The  second  step  is  intimately  related  to 
the  first.  It  would  consist,  primarily,  of 
recognition  of  the  fact  that  it  is  through  the 
operation  of  the  medical  college  and  its  teach- 
ing hospital  by  the  University  that  the  medi- 
cal profession  of  this  state  meets  its  ancient 
obligation  to  reproduce  itself  through  the 
education  of  future  physicians.  This  recog- 
nition would  then  be  implemented  by  shap- 
ing all  the  policies  of  the  teaching  hospital 
toward  its  improvement  as  a setting  for 
education,  and  by  strengthening  the  faculty 
— both  paid  and  voluntary — to  the  end  that  it 
can  do  an  effective  job  with  its  already  large 
educational  program.  At  the  present  time  a 
large  number  of  fine  physicians  are  nominal- 
ly members  of  the  faculty,  but  the  fact  is 
that  a considerable  number  of  them  are  so 


heavily  committed  to  their  own  patients  and 
to  the  programs  of  other  hospitals  that  they 
are  not  in  a position  to  carry  much  of  the 
faculty  load.  The  active  faculty  in  all  the 
clinical  departments — both  paid  and  volun- 
tary— totals  something  less  than  70  people, 
and  they  must  carry  the  responsibility  for 
the  education  of  160  students  in  the  third  and 
fourth  years,  and  more  than  120  interns  and 
residents,  as  well  as  research  programs  and 
supervision  of  the  care  of  a substantial  num- 
ber of  patients. 

With  the  continued  support  of  the  mem- 
bers of  this  Association  we  can  recruit  an 
adequate  number  of  well  qualified  students, 
strengthen  the  educational  program,  and 
look  forward  to  a time  when  the  enrollment 
can  be  expanded  in  the  existing  program 
or  a second  medical  school  developed,  but  it 
will  take  strenuous  effort  and  full  under- 
standing and  support  of  the  members  of  this 
Association. 


LYMPHOSAKCOMA 

Extensive,  Apparently  Hopeless  Gastric 

Tumor  May  Be  a Sarcoma  Treatable  by 

Irradiation. 

Lymphosarcoma  is  the  most  common  sar- 
coma of  the  digestive  system,  comprising  60 
to  70  percent  of  the  malignant  gastric  tumors 
of  mesenchymal  origin.  A large,  extensively 
spread  tumor  of  the  stomach,  assumed  to  be 
a hopelessly  inoperable  cancer,  might  be  a 
sarcoma  sensitive  to  radiation.  The  explora- 
tory operation  should  not  be  closed  without 
biopsy. 

Other  tumors  of  mesenchymal  origin  in 
the  stomach  are  chiefly  leiomyosarcomas  and 
occasionally  fibrosarcomas.  A leiomyosar- 
coma may  develop  in  a pre-existing  leiomy- 
oma. Fibrosarcomas  are  of  relatively  low 
malignancy. 

Treatment  of  lymphosarcoma  should  be  re- 
section if  possible  followed  by  irradiation, 
irradiation  alone  if  not  resectable.  The  other 
sarcomas  are  resistant  to  irradiation  and  sur- 
gical excision  is  the  only  hope  for  a cure. 
The  prognosis  for  sarcoma  of  the  stomach  is 
generally  better  than  that  for  epithelioma. 


JULY  I960— VOL.  30,  NO.  I 


21 


ARTHRITIS  SUFFERERS 
CRUELLY  EXPLOITED 

Arthritis  sufferers  are  spending  more  than 
$250,000,000  a year  for  “misrepresented  drugs, 
devices,  and  treatments  most  of  which  are 
worthless  and  unduly  expensive.” 

This  estimate,  based  on  a careful  survey 
by  a committee  of  the  Arthritis  and  Rheuma- 
tism Foundation,  is  contained  in  a new 
pamphlet.  The  Arthritis  Hoax,  published  re- 
cently by  the  Public  Affairs  Committee. 

The  survey  found  that  “patently  dishonest 
or  misleading  claims  are  widely  advertised 
for  literally  hundreds  of  products.” 

“Because  no  specific  cure  is  available,”  the 
pamphlet  indicates,  “the  arthritic’s  often 
agonizing  aches  and  pains  drive  him  to  try 
anything  which  promises  relief.  Records 
show  that  57  per  cent  of  the  arthritics  using 
proprietary  products  buy  at  least  one  that  is 
misrepresented.” 

“The  advertising  is  lurid  and  extremely 
tempting  to  the  arthritis  sufferer,”  the 
pamphlet  points  out.  “Many  of  the  products 
which  promise  relief  from  pain  have  as  their 
only  pain-reducing  ingredient  . . . plain  or- 
dinary aspirin  which  can  be  bought  a lot 
cheaper.” 

“Liniments,  ointments,  and  lotions,  many 
of  which  provide  temporary  relief  from 
minor  arthritic  aches,  are  not  among  the 
misrepresented  products  as  a group,”  the 
report  declares.  “As  with  aspirin,  many 
furnish  some  measure  of  temporary  relief. 
It  is  only  when  they  make  further  claims 
of  therapeutic  values  that  they  come  into 
conflict  with  federal  law  enforcement  of- 
ficials.” 

In  a different  category,  however,  are  the 


Sditorials 


“spas,  resorts,  clinics,  and  ‘uranitoriums’  that 
are  not  only  expensive  but  raise  false  hopes.” 

“Uranitoriums,”  for  example,  “which  have 
sprung  up  all  over  the  country,  have  lured 
thousands  many  miles.  In  one  year,  250,000 
people  from  the  East  Coast  alone  journeyed 
to  Texas  to  take  uranium  mine  treatments. 
In  eighteen  months,  more  than  100,000  per- 
sons patronized  a mine  in  the  Mountain 
States.” 

“The  amount  of  radiation  . . . has  been 
checked  and  found  to  be  about  equal  to  that 
received  from  an  illuminated  watch  dial.  This 
is  the  one  fortunate  aspect  of  the  whole 
swindle,”  the  pamphlet  declares,  “for  other- 
wise the  patients  would  suffer  radiation 
burns.” 

Other  fallacies  and  fancies,  the  report 
shows,  lay  in  the  field  of  diet  and  food 
supplements.  Contrary  to  many  claims,  “no 
special  diet  or  food  supplement  can  either 
cause  or  cure  the  ailment.  A well-balanced 
diet  is  important  for  the  arthritic — as  it  is 
to  everyone.” 

MEDICAL  CARE  COSTS 

Costs  of  medical  care  for  indigent  older 
people  will  continue  to  be  high  in  the  future 
despite  economy  measures,  a leading  authori- 
ty predicted  recently. 

Dr.  I.  Jay  Brightman,  executive  director 
of  the  New  York  Interdepartmental  Health 
Resources  Board,  told  the  National  Health 
Forum  in  Miami  Beach  that  the  number  of 
Old  Age  Assistance  recipients  is  decreasing 
but  the  cost  of  caring  for  them  is  increasing. 

“There  is  no  reason  for  surprise  or  alarm  at 
increasing  costs,”  he  said.  “When  dealing 
with  an  older  population  we  can  expect  them 


22 


J.  M.  A.  ALABAMA 


EDITORIAL  SECTION 


to  have  greater  medical  needs,  and  the  in- 
digent aged  have  greater  medical  needs 
than  the  non-indigent.  We  must  remember 
that  better  medical  care  is  keeping  patients 
alive  longer  and  this  increased  life  is  often 
dependent  upon  even  more  expensive  medi- 
cal care.  A look  around  any  nursing  home 
will  convince  any  skeptic.” 

Dr.  Brightman  outlined  several  possible 
ways  to  effect  economies  in  medical  care  but 
warned  against  measures  that  might  threaten 
quality  of  care. 

“In  the  long  run,  good  medical  care  is  the 
least  expensive  form  of  medical  care,  re- 
gardless of  social  group,”  he  said. 

“One  possible  way  of  reducing  the  num- 
bers of  Old  Age  Assistance  recipients  in  the 
future,”  he  said,  “is  through  better  social 
planning  in  terms  of  personal  provisions  for 
income  maintenance  and  health  insurance 
that  will  enable  more  older  people  to  be 
independent.” 

“Intensive  medical  care  and  rehabilitation 
services  may  permit  a few  to  leave  the  wel- 
fare roles  after  they  have  entered  them,”  he 
said.  “Provision  of  these  services  should  be 
a dynamic  part  of  the  welfare  medical  care 
program.  It  may  be,  however,  that  there  will 
always  be  older  persons  whose  social,  eco- 
nomic and  health  reverses  will  bring  them  to 
the  public  assistance  level  as  well  as  those 
so-called  ‘marginal’  individuals  who  never 
really  rise  above  that  level  throughout  life.” 

“In  reducing  costs  of  welfare  medical  care, 
abuses  must  be  controlled,”  he  said,  adding 
that  “this  applies  to  abuses  by  the  recipients, 
by  physicians,  by  druggists  and  all  others 
concerned  with  the  program.” 

But  he  added  that  experience  in  New  York 
State  has  indicated  that  abuses  are  “quite 
minimal”  and  that  “offenders  can  be  quickly 
spotted  by  a reasonably  vigilant  program.” 

“Excessive  controls,  such  as  requirements 
for  pre-authorizations  of  physicians’  visits 
and  limitations  of  numbers  of  calls  allowed 
on  a single  authorization,  add  nothing  to  a 
program  except  red  tape,”  he  added. 

Dr.  Brightman  also  warned  that  “special 


schemes  for  reducing  costs  through  employ- 
ment of  panel  physicians  and  utilization  of 
clinics  and  other  mechanisms  have  the  haz- 
ard of  reducing  quality  of  care.”  He  referred 
to  “one  large  city  where  the  physicians’  panel 
is  made  up  largely  of  physicians  who  do  not 
hold  appointments  to  accredited  hospitals.” 

As  to  high  cost  of  drugs  and  medical  sup- 
plies for  welfare  recipients.  Dr.  Brightman 
commented  that  “this  is  hardly  surprising  in 
view  of  the  studies  of  drugs  costs  for  the 
population  as  a whole  and  the  recent  con- 
gressional hearings  on  this  subject.” 

He  said  that  many  recently  developed 
drugs  are  “very  expensive”  and  must  be  pre- 
scribed because  they  are  “distinctly  superior 
to  all  others.” 

“On  the  other  hand,”  he  said,  “it  is  equally 
evident  that  prescribing  drugs  by  generic 
names  can  result  in  decreases  in  costs.  In 
New  York,  the  State  Department  of  Social 
Welfare  has  strongly  encouraged  public  wel- 
fare agencies  to  insist  upon  generic  names 
whenever  possible  and  this  has  been  endorsed 
by  several  county  medical  societies  although 
resisted  by  others.” 

In  the  area  of  administrative  mechanisms 
for  providing  medical  care,  there  is  room  for 
much  experimentation.  Dr.  Brightman  de- 
clared. 

“We  need  more  studies  of  cooperative  ar- 
rangements whereby  health  departments, 
health  insurance  plans  or  special  bureaus  of 
medical  societies  accept  this  responsibility  in 
behalf  of  the  welfare  agency,”  he  said. 

91  MILLION  NOW  HAVE  POLIO  SHOTS 

New  estimates,  released  by  the  Public 
Health  Service  recently,  show  that  over  91 
million  persons  have  now  had  one  or  more 
shots  of  polio  vaccine  and  72  million  of  them 
have  had  the  three  or  more  shots  required 
for  complete  vaccination. 

The  estimates  were  developed  by  the  Na- 
tional Foundation  with  data  supplied  by  the 
Public  Health  Service  and  local  chapters  of 
the  Foundation. 

The  new  figures  indicate  that  40  per  cent 


JULY  I960— VOL.  30,  NO.  I 


23 


EDITORIAL  SECTION 


of  the  population  now  have  maximum  pro- 
tection against  polio.  Eleven  per  cent  have 
been  partially  vaccinated  with  one  or  two 
injections,  but  49  per  cent  have  had  no  vac- 
cine at  all. 

“It  is  among  these  49  per  cent  that  para- 
lytic polio  will  take  its  heaviest  toll  this 
summer,”  warned  Dr.  John  D.  Porterfield, 
Acting  Surgeon  General  of  the  Public  Health 
Service. 

Among  children  under  five  years  of  age, 
who  accounted  for  43  per  cent  of  all  paralytic 
polio  cases  last  year,  there  are  still  8.5  mil- 
lion, or  42  per  cent  of  all  children  in  that  age 
group,  who  have  had  less  than  the  three  or 
more  shots  required.  Nineteen  per  cent  of 
them  have  had  no  vaccine  at  all. 

PENICILLIN  TREATMENT  FOR 
RHEUMATIC  FEVER 

The  Rheumatic  Fever  Committee  of  the 
American  Heart  Association  has  recom- 
mended the  following  treatment  schedules 
with  penicillin,  stressing  that  sulfonamides 
are  not  effective  in  preventing  rheumatic 
fever,  except  in  the  prophylaxis  against 
streptococcal  infection. 

In  cases  of  penicillin  sensitivity,  erythro- 
mycin should  be  given  for  ten  days.  Tetra- 
cycline should  be  used  in  patients  sensitive 
to  both  penicillin  and  erythromycin. 

RECOMMENDED  TREATMENT  SCHEDULES 
INTRAMUSCULAR  PENICILLIN 

Method  A — a single  injection  containing 

600.000  units  of  Benzathine  G and  600,000 
units  Procaine  Penicillin. 

Children  and  Adults:  One  injection  for 

both  children  and  adults  is  sufficient  to  pro- 
vide protection  for  the  full  ten  days. 

Method  B — Procaine  Penicillin  with  alumi- 
num monostearate  in  oil. 

Children;  one  intramuscular  injection  of 

300.000  units  every  third  day  for  three  doses. 

Adults:  one  intramuscular  injection  of 

600.000  units  every  third  day  for  three  doses. 


ORAL  PENICILLIN 

Any  oral  Penicillin 

Children  and  Adults:  800,000  units  daily  in 
divided  doses  of  200,000  units  for  ten  days. 
(Before  meals  and  at  bedtime). 

Properly  administered,  the  oral  and  intra- 
muscular regimens  are  equally  effective.  The 
physician  should  take  into  consideration  the 
fact  that  the  oral  program  is  often  not  faith- 
fully followed  and  that  sensitivity  reactions 
may  be  more  frequent  and  severe  following 
intramuscular  injections. 

AMERICAN  THORACIC  SOCIETY 

The  medical  section  of  the  National  Tuber- 
culosis Association  has  changed  its  name 
from  the  American  Trudeau  Society  to  the 
American  Thoracic  Society,  according  to  a 
recent  announcement  by  James  E.  Perkins, 
M.D.,  NTA  managing  director. 

The  new  name.  Dr.  Perkins  pointed  out,  re- 
flects more  accurately  the  broad  interest  of 
the  membership  in  all  diseases  of  the  chest 
and  respiratory  tract,  as  well  as  tuberculosis. 

“It  seemed  that  the  time  had  come,”  said 
Dr.  Perkins,  “for  the  name  of  the  ATS  to 
reflect  the  current  scientific  interests  of  the 
membership,  reluctant  as  it  was  to  relinquish 
the  name  of  Dr.  Edward  L.  Trudeau,  the 
great  physician  who  pioneered  in  the  treat- 
ment and  research  of  tuberculosis  and  who 
was  the  first  president  of  the  National  Tuber- 
culosis Association. 

Organized  in  1905  as  the  American  Sana- 
torium Association,  the  ATS  was  reorganized 
in  1939  as  the  medical  section  of  the  NTA 
and  named  in  honor  of  Dr.  Trudeau,  who 
established  the  famous  sanatorium  that  bore 
his  name  at  Saranac  Lake,  N.  Y.  The  Society 
has  a membership  of  more  than  5,000  physici- 
ans and  other  scientists  in  North  America 
and  throughout  the  world.  Its  official  sci- 
entific journal  is  the  American  Review  of 
Respiratory  Diseases. 


24 


J.  M.  A.  ALABAMA 


President’s  Page 


ABOUT  CANCER 


In  a recent  statement  of  figures  concerning 
cancer  it  was  stated  that  “in  the  United  States 
today  there  are  living  one  million  cases  of 
cured  cancer.”  But  on  the  dark  side  of  the 
picture  we  read  that  “five  hundred  thousand 
deaths  occur  annually  from  this  dread  dis- 
ease.” Of  this  number,  approximately  two 
hundred  fifty  thousand,  or  one-half  of  this 
number,  might  be  salvaged  with  our  pos- 
sessed knowledge  of  cancer,  “if  only  the  peo- 
ple could  be  educated  and  persuaded  and 
made  to  realize  the  vital  importance  of  avail- 
ing themselves  of  early  diagnostic  facilities.” 

Briefly,  the  treatment  of  cancer  can  be  di- 
vided into  two  classifications,  curative  and 
palliative.  Under  the  curative  treatment  we 
can  include,  of  course,  surgery — radical  and 
ultra-radical — and  irradiation.  In  palliative 
therapy  we  can  keep  in  mind  two  methods  of 
treatment — active  or  passive. 

In  active  palliative  we  can  include  X-ray 
and  radium  along  with  selective  surgery  to 
correct  problems,  bearing  in  mind  always  the 
comfort  of  the  patient  and  the  prolonging 
of  life.  Among  these  procedures  we  might 
include  defunctionating  colostomy  to  prevent 
or  overcome  the  possibility  of  a large  bowel 
obstruction  in  malignances.  In  the  case  of 
breast  cancer  we  might  consider  removal  of 
the  ovaries  or  adrenals  and  the  hypophysis. 
Further  discussion  of  this  is  forthcoming. 
Along  with  this  we  can  of  course  prescribe 
hormones  and  cancerocidal  chemicals,  includ- 
ing perfusion. 

In  passive  palliation  we  must  concern  our- 
selves with  both  the  mental  and  physical 


comfort  of  the  patient.  Psychologically,  we 
must  have  an  approach  of  cheerfulness  and 
hopefulness.  An  estimated  length  of  time 
which  the  patient  might  expect  to  live  seems 
to  us  to  be  bad.  At  best  it  is  a “guess.”  The 
patient  is  not  helped  by  it,  nor  does  it  do 
anything  to  alleviate  his  anxiety.  He  may 
even  live  long  enough  to  contract  another 
disease  which  might  cause  his  death.  Too 
many  men  of  the  medical  profession  have 
been  taken  to  task  by  the  public  for  attempt- 
ing just  such  “guesses.” 

A very  vital  factor  in  the  treatment  of  the 
patient  is  good  nursing  care — along  with 
judicious  selection  of  agents  to  relieve  pain 
and  promote  comfort  for  the  patient.  Good 
nursing  care  is  greatly  to  be  sought.  This  can 
do  much  for  the  mental  as  well  as  the  physi- 
cal welfare  of  the  patient.  This  should  be 
mentioned  with  the  hope  that  narcotics  may 
become  necessary  only  in  advanced  stages  or 
perhaps  not  at  all. 

How  active  should  palliative  treatment  be? 
Re-exploration  in  intra-abdominal  cases  has 
been  advised.  How  often  and  how  many 
times  should  this  be  done?  A patient  had 
resection  of  the  small  bowel  for  rhabdomyo- 
sarcoma. Eight  years  later  she  was  resected 
for  neurogenic  sarcoma  of  the  small  bowel 
mesentery.  The  same  disease  process? 

Of  how  much  value  is  glandular  resections? 
To  quote  Dr.  Alvarez  of  the  Mayo  Clinic,  it 
may  mean  only  added  suffering  for  the  pa- 
tient with  possible  financial  bankruptcy  for 
the  family. 


JULY  I960— VOL.  30,  NO.  I 


25 


PRESIDENT'S  PAGE 


Irradiation  carries  a risk  which  must  be 
most  diligently  evaluted.  There  is  possible 
danger  of  damage  to  the  lung,  to  the  bowel, 
and  to  the  skin.  Chemicals  too  must  be  care- 
fully considered.  They  may  sometime  cause 
increased  pain  and  morbidity.  Perfusion  is 
limited  mainly  to  the  extremities.  Its  use 
internally  is  questionable  at  this  time.  As 
has  been  previously  stated,  hormones  are 
frequently  helpful  when  indicated. 

Palliative  treatment  is  not  always  easy. 
In  consultation  with  his  fellow  member  in 
the  profession,  and  always  with  his  own  con- 
science and  thinking,  the  physician  can  usu- 
ally arrive  at  a satisfactory  answer.  This 
can  do  much  to  guide  him  in  his  treatment. 
It  can  help  him  decide  just  how  much  might 
be  indicated.  Someone  has  said,  “Do  no 
harm!” 


a year  or  oftener.  (3)  Let  us,  the  physicians, 
continue  to  strive  for  a satisfactory  test  for 
early  diagnosis.  Let’s  hope  and  pray  for 
an  early  discovery  of  the  cause  and  for  a 
cure. 

In  the  meantime,  let’s  continue  to  use  all  of 
our  training  and  our  experience  to  alleviate 
as  much  as  possible  the  pain  and  the  ravages 
of  cancer.  In  prolonging  life  in  these  cases, 
may  we  always  consider  the  comfort  and  the 
welfare  of  the  patient. 


For  the  present  let  us  keep  in  mind  these 
things:  (1)  Let  there  be  no  letup  whatso- 

ever in  educating  the  public  concerning  the 
disease.  (2)  Let’s  make  them  realize,  with- 
out stopping,  how  very  vital  is  the  need  for 
periodic  physical  examination — at  least  one 


PHILANTHROPIC  CONSTRUCTION  TO 
HIT  RECORD  IN  I960 

Construction  of  non-profit  hospital,  church, 
and  educational  facilities  is  likely  to  reach  a 
new  record  in  1960.  The  forecast  was  made 
today  (Wednesday,  June  29)  by  The  Ameri- 
can Association  of  Fund  Raising  Counsel,  Inc., 
based  on  construction  gains  for  the  first  five 
months. 

The  Association  reported  construction  was 
19  per  cent  ahead  of  the  same  period  in  1959 
and  totaled  $847  million. 

The  Association  estimated  that  $33  billion 
for  college  and  university  plant  development 
will  be  required  by  1970.  To  meet  this  figure, 
some  $3  billion  annually  for  the  next  decade 
will  be  needed.  If  the  proportion  of  philan- 
thropic support  continues  at  the  present  level 
philanthropic  giving  to  higher  education 
alone  may  reach  $1.25  billion  annually  by 
1970. 


Based  on  the  five  month  reports,  the  As- 
sociation indicated  that  hospital  construction 
may  total  $675  million  this  year,  possibly 
making  1960  the  greatest  growth  year  in  a 
decade.  An  estimated  $300  million  of  total 
construction  costs  may  be  expected  to  come 
from  private  sources. 

The  AAFRC  is  a non-profit  organization 
of  31  major  national  fund  raising  firms  spe- 
cializing in  counseling,  directing,  and  organ- 
izing fund  raising  activities  in  the  U.  S.  and 
Canada. 


26 


J.  M.  A.  ALABAMA 


CIVIL  DEFENSE 


Montgomery,  Alabama,  has  been  selected 
as  one  of  the  pilot  cities  for  the  organization 
of  the  National  Civil  Defense. 

It  is  obvious  that  no  civil  defense  program 
can  operate  without  full  cooperation  of  all 
health  facilities. 

To  meet  this  problem  the  Disaster  Com- 
mittee of  the  Montgomery  County  Medical 
Society  has  worked  out  a model  plan  that 
can  be  used  in  other  cities  throughout  the 
country. 

The  committee  has  evolved  this  plan  in  co- 
operation with  the  Civil  Defense  Authority. 

Ideas  on  civil  defense  are  changing  from 
time  to  time  and  are  subject  to  changes  by 
the  Civil  Defense  Authority. 

This  committee  has,  however,  attempted 
to  keep  abreast  of  time  by  constantly  revis- 
ing the  plan. 

Although  Civil  Defense  is  primarily  in- 
terested in  a national  disaster  which  is  usu- 
ally thought  of  in  terms  of  atomic  and  hydro- 
gen warfare,  the  Montgomery  County  So- 
ciety’s plan  takes  into  consideration  local 
disasters,  so  that  physicians  and  allied  per- 
sonnel could  take  unilateral  action  without 
aid  from  the  National  Disaster  Authority. 

The  physician  plays  a most  vital  part  in 
our  survival. 

CIVIL  DEFENSE  MEDICAL  SERVICES  SECTION 

I.  MISSION  OF  SECTION 

To  mobilize,  and  coordinate  the  use  of,  the 
professional  manpower  and  material  medical 
resources  of  the  county  to  safeguard  the 


lives  and  health  of  the  population  in  a dis- 
aster situation. 

II.  PARTICIPATING  ORGANIZATIONS 

1.  Medical  Society  of  Montgomery  County. 

2.  Montgomery  County  Health  Depart- 
ment. 

3.  Montgomery  County  Dental  Associa- 
tion. 

4.  Montgomery  County  Veterinary  Medi- 
cal Association. 

5.  Registered  Nurses  and  Medical  Techni- 
cians. 

6.  Physicians  not  members  of  Medical  So- 
ciety of  Montgomery  County. 

7.  Montgomery  Hospitals. 

8.  Montgomery  County  Pharmaceutical 
Association. 

9.  Morticians. 

10.  Ambulance  Companies. 

11.  Veterans  Administration  Hospital  (on 
cooperating  basis  only) . 

12.  Southeast  Radiological  Health  Facility 
(on  cooperating  basis). 

III.  ORGANIZATION 
A.  Command 

1.  Chief  of  Medical  Section  shall  be  the 
chairman  of  the  standing  Disaster  Commit- 
tee of  the  Montgomery  County  Medical  So- 
ciety. 

2.  The  Chief  of  Medical  Section  shall  co- 
ordinate the  efforts  and  assignments  of  the 
participating  organizations,  which  comprise 
the  major  sources  of  professional  and  non- 
professional personnel.  He  shall  assume  di- 


JULY  I960— VOL.  30.  NO.  I 


27 


ORGANIZATION  SECTION 


rect  command  of  the  Section  in  the  event  of 
an  emergency.  He  may  revise  assignments 
and  missions  as  situations  require. 

3.  Succession  of  command  will  pass  in 
order  to  the  Deputy  Chief  of  Medical  Section, 
Chief  of  Hospital  Services  Division,  and 
Chief  of  Field  Services  Division. 

B.  Staff 

The  staff  of  the  Chief  of  Medical  Serv- 
ices Section  shall  consist  of  his  Deputy,  the 
Chief  of  each  Division,  and  the  Deputy  Chief 
of  each  Division. 

C.  Divisions 

1.  Hospital  Division 

Mission — care  of  injuries  and  surgical 
emergencies  in  a disaster  situation,  due  either 
to  natural  causes  or  to  enemy  action,  using 
existing  hospital  facilities  and  field  hospitals 
if  required.  Mission  will  include  care  of  pa- 
tients in  hospitals  who  cannot  be  evacuated 
to  shelters  during  periods  of  exposure  of  the 
community  to  high  radiation  levels. 

2.  Field  Services  Division 

A.  Mission — The  Medical  Services  Divi- 
sion shall  organize  professional  personnel  for 
the  purpose  of  providing  medical  care  to 
individuals  in  a disaster  area.  This  is  in  con- 
tradistinction to  collection  and  transportation 
of  sick  and  wounded,  surgical  treatment,  and 
matters  pertaining  to  public  health. 

B.  This  will  include  establishment  of 
medical  service  or  aid  stations  for  outpatient 
care  and  classification  of  illness  or  injury, 
providing  visiting  physician  care  to  emer- 
gency housing  areas,  staffing  of  designated 
medical  stations  during  periods  of  exposure 
of  community  to  high  radiation  levels,  and, 
at  direction  of  Chief  of  Medical  Section,  care 
of  hospitalized  patients  after  initial  treat- 
ment if  physicians  assigned  to  Hospital 
Service  Division  are  all  occupied  with  emer- 
gency treatment  of  casualties. 

3.  Public  Health  Services  Division 

Mission — performing  the  essential  public 
health  services:  sanitation,  preventive  medi- 
cine, supervision  of  emergency  burial  proce- 


dures, and  detection  of  contamination  of  food 
and  water  supplies  within  the  area. 

4.  Medical  Supply  Division 

Mission — estimation  of  medical  supplies 
available  for  care  of  population  during  dis- 
aster situations,  with  summary  to  be  report- 
ed to  Chief  of  Medical  Service  Section  an- 
nually. 

During  a disaster  situation,  the  Section 
will  maintain  a constant  inventory  of  medi- 
cal supplies  and  replace  supplies  as  con- 
sumed. 

5.  Communication  and  Liaison  Division 

Mission — maintenance  of  liaison  with  the 
Communication  Section  and  Transportation 
Section  of  the  Montgomery  County  Civil  De- 
fense organization.  The  Chief  of  Division 
shall  assume  command  of  whatever  commu- 
nications and  transportation  facilities  may 
be  available  to  the  Medical  Services  Section. 

D.  Assignment  of  personnel 

1.  Personnel  shall  be  given  duty  assign- 
ments by  the  Staff  of  the  Medical  Services 
Section,  subject  to  the  approval  of  the  Chief 
of  the  Section.  Assignment  lists  are  to  be 
attached  as  Appendix  9-3  and  shall  be  revised 
or  authenticated  at  least  twice  a year,  and  a 
dated  copy  filed  with  the  Director  of  Civil 
Defense. 

2.  The  reverse  side  of  the  membership 
card  of  each  member  of  the  participating  or- 
ganizations shall  carry  the  duty  assignment 
of  the  member. 

3.  Each  participating  organization  shall 
be  provided  with  complete  data  on  organiza- 
tion and  operation  of  the  Medical  Service 
Section. 

IV.  GENERAL  INFORMATION 

A.  Activation  . . . The  section  will  be  ac- 
tivated by  order  of  proper  authority. 

B.  Warning  ...  of  an  attack  upon  this 
country  or  the  imminence  of  a natural  dis- 
aster will  be  received  at  the  Doctors  Ex- 
change from  the  Fire  Alarm  Headquarters. 
(Notification  from  any  other  source  should 
be  verified  with  the  Fire  or  Police  Depart- 


28 


J.  M.  A.  ALABAMA 


ORGANIZATION  SECTION 


ments  or  the  Director  of  Civil  Defense.) 

The  operator  on  duty  at  the  Doctors  Ex- 
change shall  immediately  notify  the  Chief  of 
the  Medical  Services  Section  and  his  staff. 

C.  Communication  ...  by  telephone  and 
by  special  radio  circuits  provided  by  the 
Director  of  Civil  Defense,  as  available  and  as 
required  by  the  situation.  List  of  unlisted 
phones  at  City  Hall  and  other  key  points 
should  be  maintained  by  the  Communications 
Division,  along  with  listed  priority  numbers 
at  established  public  shelters  and  medical 
aid  stations. 

The  alternate  location  of  the  Doctors  Ex- 
change shall  be  at  Room  of  City  Hall,  and 
identical  card  files  shall  be  maintained  at 
this  point.  (Cards  will  be  prepared  by  the 
Doctors  Exchange  personnel  and  mailed  to 
the  Office  of  Civil  Defense  for  filing.)  Two 
telephone  lines  will  be  reserved  for  use  of 
Medical  Services. 

D.  Safety  of  families  of  participating 
PERSONNEL  . . . Each  person  participating 
should  be  cautioned  to  pre-plan  his  family’s 
actions  during  a fallout  emergency.  It  is  sug- 
gested that  under  Plan  A,  families  remain  at 
home;  under  Plan  B to  seek  shelter  in  the 
building  at  which  the  husband  or  wife  is 
assigned  as  a member  of  a medical  team. 

E.  Traffic  Movement:  Participating  per- 
sonnel holding  key  assignments  will  be  given 
every  assistance  by  the  Police  Department  in 
reaching  their  destinations  through  congest- 
ed areas.  Under  Plan  B an  attempt  will  be 
made  to  close  South  Court  Street  to  all  ex- 
cept vehicles  with  such  priority  assignments. 
If  possible  advance  notice  of  Plan  B will  be 
given  to  medical  teams  through  the  Doctors 
Exchange  or  coded  broadcast  message. 

V.  IMMEDIATE  STEPS  AFTER  NOTICE  OF 
ATTACK  ON  UNITED  STATES 

A.  Doctor’s  Exchange: 

1.  Upon  notice  of  the  attack  the  operator 
on  duty  shall  immediately  alert  the  following 
persons  and  if  possible  advise  them  of  the 
situation: 

Chief  of  Medical  Services  and  his  Deputy. 


The  Chief  of  each  Medical  Service  Division 
and  his  Deputy. 

Such  other  persons  as  directed  by  the 
above  officers,  depending  on  the  situation. 

2.  As  soon  as  possible,  each  Division 
Chief  shall  determine  which  of  the  personnel 
assigned  to  his  teams  are  present  for  duty. 

3.  One  or  more  operators  should  be  dis- 
patched to  the  Alternate  Doctors  Exchange. 

B.  The  Chief  of  Medical  Services  and 
HIS  Staff:  shall  report  immediately  to  Civil 
Defense  Headquarters. 

VI.  ACTION  UNDER  PLAN  A 
(Light  Fallout  Condition) 

A.  General:  Since  communications  are 

expected  to  be  taxed  to  the  maximum,  all 
assigned  personnel  should  proceed  to  their 
stations  automatically  upon  hearing  of  the 
implementation  of  Plan  A.  After  the  arrival 
of  fallout,  assigned  personnel  are  not  to  leave 
their  shelter  for  any  reason  without  the  ap- 
proval of  the  Chief  of  Medical  Services.  Any 
person  needing  medical  attention  must  pro- 
ceed to  the  nearest  aid  station  or  hospital. 

B.  The  Chief  of  Medical  Services  . . . 
shall  remain  at  Civil  Defense  Headquarters 
on  the  Staff  of  the  Director  of  Civil  Defense. 
The  remainder  of  the  Staff  shall  assume  as- 
signed duties.  (All  personnel  should  be  cau- 
tioned that  Plan  A might  be  called  only  as  a 
transition  to  Plan  B and  to  modify  their  ac- 
tions accordingly.) 

C.  Hospital  Service  Division:  Assigned 
medical  and  surgical  teams  shall  report  to 
assigned  stations. 

The  Chief  Surgeon  of  each  hospital  shall 
immediately  determine  which  staff  members 
are  present  and  available  for  duty.  Pa- 
tients and  staff  in  each  hospital  shall  be  relo- 
cated in  accordance  with  Basic  Survival  In- 
structions. The  Hospital  Administrator  shall 
be  responsible  for  obtaining  any  supplies 
necessary  for  a three-day  stay. 

Patients  and  staff  of  the  Montgomery 
Tuberculosis  Sanitorium  shall  be  moved  to 
an  appropriate  building. 

D.  Field  Services  Division:  Assigned 

pairs  of  doctors  shall  report  to  each  Plan  A 


JULY  I960— VOL.  30,  NO.  I 


29 


ORGANIZATION  SECTION 


Medical  Aid  Station.  Headquarters  of  the 
Division  shall  be  at  Room  of  the  City  Hall. 

The  assigned  licensed  Pharmacist  shall 
report  to  each  Medical  Aid  Station.  Where 
the  aid  station  is  not  located  in  an  existing 
Pharmacy,  he  shall  bring  with  him  a stock 
of  medical  supplies  made  up  for  that  occasion. 

E.  Communication  and  Liaison  Division: 
The  movement  of  the  Doctors  Exchange  to 
its  alternate  location  shall  be  verified,  and 
that  facility  shall  serve  as  the  primary  com- 
munication system. 

The  secondary  communication  system  shall 
be  via  radio  circuits  furnished  under  the  Civil 
Defense  Communications. 

Ambulance  units  will  report  to  each  hos- 
pital for  any  use  approved  by  the  Chief  of 
Medical  Services.  Volunteer  drivers  should 
be  recruited  from  any  nontechnical  person- 
nel at  each  hospital  to  limit  the  number  of 
trips  made  by  any  one  driver. 

F.  Public  Health  Services  Division: 
Headquarters  of  the  Division  shall  remain  at 
the  County  Health  Center.  Assigned  func- 
tions will  be  carried  out. 

Preparations  will  be  made  for  the  estab- 
lishment of  a food  and  water  testing  labora- 
tory. 

VII.  ACTION  UNDER  PLAN  B 
(Heavy  Fallout  Condition) 

A.  General:  Since  all  communications 

will  be  taxed  to  the  maximum,  all  assigned 
personnel  should  proceed  to  their  stations 
automatically  upon  hearing  of  the  implemen- 
tation of  Plan  B. 

After  the  arrival  of  fallout,  assigned  per- 
sonnel are  not  to  leave  their  shelter  for  any 
reason  without  approval  of  the  Chief  of  Medi- 
cal Services.  Any  person  needing  more  elab- 
orate medical  attention  than  is  available  in 
his  shelter  must  proceed  at  his  own  risk  to 
the  nearest  hospital  facility. 

B.  Chief  of  Medical  Services  and  his 
Deputy  and  each  Division  Chief  shall  hold 
their  positions  as  under  Plan  A,  except  as 
otherwise  noted. 


C.  Hospital  Services  Division: 

1.  Hospital  service  teams  shall  report  to 
and  begin  organization  of  each  hospital  as 
under  Plan  A.  Patients  and  staff  shall  be 
relocated  within  the  building,  and  precau- 
tions taken  in  accordance  with  Basic  Survival 
Instructions  and  as  required  to  facilitate  use 
of  the  building  as  a Public  Shelter  where  so 
designated. 

2.  Respective  hospital  administrators  will 
be  responsible  for  a seven  day  stay,  and  shall 
act  in  the  capacity  of  Shelter  Commander 
over  the  occupants  of  the  Public  Shelter. 

3.  Patients  and  staff  of  the  Tuberculosis 
Sanitorium  shall  be  relocated  in  an  appropri- 
ate building  along  with  necessary  supplies 
for  several  days  stay  and  shall  be  isolated. 

D.  Field  Services  Division: 

1.  Medical  teams  shall  report  to  each 
Public  Shelter  in  accordance  with  their 
standing  assignments.  (Size  and  composi- 
tion of  teams  will  vary  according  to  the  ca- 
pacity and  disposition  of  the  shelter  areas, 
etc.) 

2.  The  Pharmacists  assigned  to  each  re- 
spective medical  team  will  secure  the  proper 
stock  of  supplies  and  report  to  that  team  in 
their  designated  shelter  location. 

E.  Communication  and  Liaison  Division: 

1.  Communication  facilities  will  be  estab- 
lished as  under  Plan  A. 

2.  Ambulance  units  will  be  stationed  at 
the  following  locations  to  transport  patients 
to  hospital  centers  upon  approval  of  the  Chief 
of  Medical  Services.  Sufficient  volunteer 
drivers  shall  be  recruited  from  adjacent  shel- 
ter occupants  to  insure  that  each  driver  will 
make  no  more  than  one  trip.  Procedures  for 
use  and  storage  of  vehicles  under  fallout  con- 
ditions are  outlined  under  Annex  A,  Basic 
Survival  Instructions. 

Exchange  Hotel  Garage — 2 vehicles 
St.  Margaret  Hospital — 1 vehicle 
St.  Judes  Hospital — 1 vehicle 
Coliseum — 1 vehicle 
Sidney  Lanier — 1 vehicle 
Lee  High  School — 1 vehicle 


30 


J.  M.  A.  ALABAMA 


ORGANIZATION  SECTION 


F.  Public  Health  Services  Division: 
Food  testing  laboratory  will  be  established  as 
under  Plan  A,  and  emergency  burial  proce- 
dures determined.  Ditching  machines  and 
necessary  transportation  will  be  available 
through  the  Transportation  Section. 

VIII.  ACTION  UNDER  PLAN  C (Evacuation) 

A.  Strategic  Evacuation:  Persons  leav- 
ing the  county  in  this  instance  would  pass 
from  the  responsibility  of  this  County  Civil 
Defense  Authority  and  no  organized  medical 
services  would  be  provided.  Medical  person- 
nel will  be  given  new  assignments  by  proper 
authority  under  the  plan  of  Medical  Associa- 
tion of  the  State  of  Alabama. 

B.  Post-Attack  Evacuation:  It  is  antici- 
pated that  under  any  remedial  movement 
sufficient  warning  would  be  available  to  per- 
mit an  organization  of  medical  services. 

IX.  ACTION  UNDER  PLAN  D 
(Reception  of  displaced  persons) 

A.  General:  Plans  are  to  be  varied  de- 
pending upon  the  number  of  persons  to  be 
received,  their  relative  state  of  health,  meth- 
od of  transportation  and  conditions  existing 
in  the  County  at  that  time.  In  general,  the 
following  guides  will  be  observed: 

1.  Except  in  special  circumstances,  recep- 
tion centers  will  be  established  by  Civil  De- 
fense Welfare  Services  (See  Section  10),  and 
medical  aid  stations  will  be  established  ad- 
jacent to  each  center  by  medical  service  per- 
sonnel. If  casualty  rates  require  it,  a sepa- 
rate field  hospital  will  be  established. 

2.  Under  heavy  fallout  conditions,  dis- 
placed persons  will  be  absorbed  into  Plan  B 
Shelters,  and  the  required  additional  medical 
personnel  and  supplies  relocated  as  leasable. 

X.  ACTION  UNDER  PLAN  E (Natural  Disasters) 

A.  General:  Specific  steps  are  to  be 

taken  as  the  situation  demands.  Each  person 
shall  proceed  directly  to  assigned  station 
under  Plan  E. 

B.  The  Chief  of  Medical  Services  . . . 
shall  immediately  set  up  his  headquarters  and 
establish  contact  with  the  Director  of  Civil 


Defense  and  key  medical  service  personnel. 
Medical  Service  Headquarters  may  be  at  City 
Hall,  any  hospital,  the  County  Health  Depart- 
ment or  in  the  disaster  area,  which  ever 
would  be  most  suitable. 

C.  Hospital  Service  Division:  Medical 

and  surgical  teams  will  report  to  their  as- 
signed hospital.  The  Chief  Surgeon  of  each 
hospital  shall  take  command  of  the  installa- 
tion and  prepare  to  receive  casualties.  Non- 
critical  patients  at  each  hospital  will  be  dis- 
charged. 

If  required,  by  Chief  of  Medical  Services, 
personnel  will  be  assembled  and  dispatched 
to  staff  a field  hospital.  Headquarters  will 
be  where  designated  by  Chief  of  Medical 
Services  Section. 

D.  Field  Services  Division:  All  medical 
teams  shall  proceed  to  their  assembly  point 
and  await  orders.  Each  team  shall  be  re- 
sponsible for  its  own  transportation. 

Locations  for  field  medical  aid  stations 
shall  be  selected  and  put  into  operation  by 
order  of  Chief  of  Division. 

Emergency  medical  supply  chests  stored 
at  the  County  Health  Center  will  be  dis- 
patched on  order  of  Chief  of  Division.  Ad- 
ditional supplies  are  to  be  procured  as  re- 
quired. 

E.  Communication  and  Liaison  Division: 
Contact  shall  be  established  with  the  Civil 
Defense  Transportation  Officer  and  request 
made  for  ambulance  vehicles  if  so  needed. 
If  contact  cannot  be  made,  this  Division  shall 
commandeer  such  vehicles  and  drivers  as  are 
needed. 

F.  Public  Health  Services  Division: 
If  conditions  warrant  testing  of  water  supply, 
emergency  burial  procedures  and  other  du- 
ties organic  to  the  Department  will  be  under- 
taken in  the  affected  areas. 

Note:  The  Civil  Defense  Authority  will 
act  only  if  the  situation  reaches  proportions 
exceeding  the  capabilities  of  other  emergency 
agencies. 


JULY  I960— VOL.  30.  NO.  I 


31 


"Miiii  was  endowed  by  God  . . . with  the  invalnahle  gift  of  health" 


AMERICA'S  HEALTH  . . . 

OURS  TO  PRESERVE 

ANITA  SMITH 


Better  health  in  America  can  never  be 
created;  it  must  essentially  be  evolved  by  the 
willingness  and  determination  of  the  Ameri- 
can people  to  combine  their  strength  and 
knowledge  in  developing,  promoting,  and 
preserving  a good  health  program  for  this 
great  nation. 

Perhaps  you  or  I would  wonder  what  our 
concern  is  in  this  ever-present  health  issue. 
The  Holy  Bible  contains  the  best  possible 
reason  for  our  concern  in  the  Book  of  Gene- 
sis: “And  God  said.  Let  us  make  man  in  our 
image,  after  our  likeness;  and  let  them  have 
dominion  over  the  fish  of  the  sea,  and  over 
the  fowl  of  the  air,  and  over  the  cattle,  and 
over  all  the  earth,  and  over  every  creeping 
thing  that  creepeth  upon  the  earth.” 

Man  was  endowed  by  God,  the  Creator, 
from  time’s  beginning  with  the  invaluable 
gift  of  health.  An  infinite  number  of  years 


Miss  Smith  is  a graduate  of  Benjamin  Russell 
High  School,  Alexander  City,  Alabama,  and  was 
second  place  winner  in  this  year’s  essay  contest. 


has  passed,  and  that  precious  gift  has  until 
this  day  not  been  reclaimed.  Just  as  man 
was  endowed  with  the  blessings  of  health,  so 
was  America  singled  out  of  the  numerous 
nations  of  the  world  to  be  the  possessor  of  the 
most  adequate  natural  healthful  surround- 
ings to  be  found  in  existence  today.  It  is, 
therefore,  our  privilege  and  duty  as  blessed 
Americans  of  this  twentieth  century  to  pre- 
serve America’s  health  for  our  own  present 
benefit  as  well  as  for  the  potential  progress 
and  well-being  of  future  generations. 

Before  we  can  fully  understand  the  needs 
of  America’s  health  in  relation  to  her  bless- 
ings, we  must  first  realize  the  meaning  of 
health.  The  dictionary  defines  health  as  a 
state  of  physical,  mental,  and  emotional  well- 
being, and  not  merely  as  the  absence  of  dis- 
ease. Although  neither  visible  nor  tangible, 
health  is  much  more  than  a mere  succinct 
definition  in  the  English  language;  it  is  a 
living  state  of  existence  which  is  alive  in  you 
and  me.  This  apparently  enigmatic  state- 
ment may  be  verified  to  some  extent  by  the 


32 


J.  M.  A.  ALABAMA 


THE  ASSOCIATION  FORUM 


following  comparison:  The  amazing  artistic 
talent  of  Leonardo  da  Vinci  could  neither 
be  viewed  by  the  human  eye  nor  touched  by 
the  human  hand;  yet  it  is  as  alive  today  in 
the  almost  unbelievable  beauty  of  the  “Mona 
Lisa”  as  if  it  had  breath  and  blood.  Like- 
wise, health  becomes  a living  embodiment 
when  it  is  possessed  by  a thoroughly  whole- 
some human  being. 

The  basic  foundation  for  a strong  Ameri- 
can health  structure  rests  on  the  shoulders 
of  the  individual  American  citizen,  you  or 
me.  However,  the  deplorable  picture  of  the 
average  citizen’s  attitude  toward  American 
health  at  the  present  time  is  this:  Mr.  and 
Mrs.  Average  Americans  are  completely  sat- 
isfied to  allow  the  doctors,  nurses,  and  re- 
search scientists  of  our  nation  preserve  and 
promote  America’s  health  standards  without 
the  assistance  of  the  public;  they  feel  that  it 
is  the  responsibility  of  such  medically  educa- 
ted professionals  to  carry  America’s  health 
burden  alone. 

People  of  this  day  and  time  are  living  in  a 
rapidly-moving  space  age;  life  is  fleeting  past 
them  so  swiftly  that  they  barely  have  the 
opportunity  to  realize  its  existence.  Although 
they  realize  the  importance  of  high  healthful 
standards  in  America,  they  have  the  miscon- 
strued conception  that  their  concern  ends 
with  this  realization,  not  with  the  promotion 
and  preservation  of  such  conditions  in  their 
own  lives.  Unfortunately,  just  as  they  are 
pushing  life  aside  for  the  “modern  pace”,  so 
are  they  neglecting  their  God-given  oppor- 
tunity to  take  part  in  the  developing  of  an 
almost  infallible  American  health  system. 

The  preservation  of  a salutary  American 
environment  does  not  demand  finesse  or  un- 
common knowledge  on  the  part  of  the  aver- 
age citizen;  it  simply  requires  the  volition 
of  one  to  utilize  practical  knowledge  in  caring 
for  the  needs  of  his  body.  However,  so  many 
people  in  the  world  have  one  of  two  common 
but  wrongly  formed  outlooks  on  health.  In- 
stead of  viewing  health  as  the  basic  founda- 
tion of  life  that  it  is,  many  think  of  it  merely 
as  a convenience;  others  know  it  only  as  a 
taken-for-granted  asset. 


The  thousands  who  look  upon  health  as  a 
convenience  will  readily  admit  that  bad 
health  can  really  be  a nuisance*  but  that 
sound  bodily  conditions  are  not  likely  to  in- 
terfere with  the  daily  routine  of  life.  But 
just  how  “convenient”  is  health?  Is  its  con- 
venience of  so  much  value  that  Mr.  Jones 
would  miss  his  favorite  late  afternoon  news 
program  to  report  to  his  family  doctor  for  a 
much-needed  physical  examination?  Is  it  so 
“convenient”  that  one  would  call  in  a body 
“repairman”  just  as  he  would  call  in  an  elec- 
trician or  a plumber?  In  other  words,  is  the 
kitchen  sink’s  condition  more  important  than 
the  condition  of  one’s  body?  Is  health’s  con- 
venience so  valuable  that  “Party-time  Pete” 
would  consent  to  relinquish  his  late  hours  at 
the  gang’s  big  parties  to  get  a few  extra 
hours  of  sleep?  Does  it  mean  so  much  to 
“Tycoon  Tex”  that  he  would  take  a few 
minutes  from  the  priceless  hours  of  office 
work  to  take  a breathing  spell? 

A convenience  is  all  too  often  a luxury 
that  is  never  realized  until  it  “runs  down”. 
It  is  a marvelous  state  of  being  as  long  as  it 
comes  out  on  top  through  8-5  working  hours, 
6-1  “rambling”  hours,  and  2-5  sleeping  hours. 
Yet  there  inevitably  comes  the  time  when 
Mr.  Bodily  Resistance  no  longer  resists  and 
a busy  man  or  woman  is  forced  to  make  sac- 
rifices in  order  to  stay  alive.  Yes,  health 
is  a convenience;  but  is  its  preservation 
worth  the  sacrifices  necessary  for  its  exist- 
ence? 

Many  others  in  this  American  twentieth 
century  feel  that  health  is  a “taken-for- 
granted”  asset.  Quite  a number  of  men  and 
women  have  convinced  themselves  that 
health  is  as  much  an  asset  as  is  charm,  per- 
sonality, or  a talent  such  as  art  or  music. 
This  idea  they  are  forcefully  driving  into  the 
minds  of  their  children,  and  the  misguided 
belief  is  becoming  more  and  more  wide- 
spread. The  idea  actually  more  closely  re- 
sembles the  opinions  of  the  ancient  witch- 
doctors of  the  dark,  obscure  islands  of  the 
Pacific  than  it  does  the  outlook  of  American 
adults  living  in  an  age  of  research  and  knowl- 
edge. The  theory  of  such  people  is  this: 


JULY  I960— VOL.  30,  NO.  1 


33 


THE  ASSOCIATION  FORUM 


Some  persons  are  lucky  enough  to  have  the 
possession  of  a sound,  healthy  body;  others 
are  not  so  lucky  and  must  survive  life  with 
a sickly,  disease-ravaged  body.  These  people 
do  not  realize  that  health  is  created  as  well 
as  granted  by  the  Almighty.  They  seem  to 
have  lost  the  knowledge  that  only  they  them- 
selves can  preserve  the  health  which  is  theirs. 

In  addition  to  the  two  wrongly  formed  out- 
looks just  discussed,  there  are  also  two  spe- 
cific types  of  human  health  hazards  who  are 
just  as  unconcerned  about  health  as  the  Can- 
cer Foundation  and  the  Tuberculosis  Foun- 
dation are  concerned.  These  persons  fall  into 
one  of  two  groups — those  who  are  self-pity- 
ing and  those  who  are  indifferent. 

There  is  a great  deal  of  difference  between 
one  who  is  concerned  about  his  health  and 
one  who  pities  his  unhealthy  condition.  Con- 
cern stimulates  self-improving  action;  self- 
pity  only  decreases  one’s  resistance  to  the 
evils  of  disease.  Actually,  a man  who  is  in- 
clined to  “mope”  but  reluctant  to  seek  medi- 
cal assistance  is  never  aware  of  his  health 
at  all  until  it  fails  him.  Instead,  he  takes  it 
for  granted  that  health  is  no  problem  at  all 
and  never  strives  to  preserve  it  in  any  way. 
However,  when  pain  and  disease  come  to  his 
door,  he  feels  that  Fate  is  against  him  and 
immediately  commences  his  self-pity.  Never 
does  he  give  a thought  to  his  carelessness  and 
negligence  of  the  needs  of  his  body.  Never 
does  the  idea  cross  his  mind  that  he  has  not 
only  failed  himself  in  the  fight  for  good 
health  but  has  also  failed  to  do  his  part  in 
maintaining  the  nation’s  standards  for  indi- 
vidual health  preservation. 

The  other  human  health  hazard  is  equal  to 
or  worse  than  that  of  the  self-pitying  man. 
He  is  the  person  who  is  completely  indiffer- 
ent toward  his  healthful  status.  This  person 
realizes  that  he  is  destroying  his  body  grad- 
ually by  self-inflicted  stabs  at  his  health  but 
refuses  to  cease  from  his  present  harmful 
actions.  He  is  the  type  of  person  who  has 
been  advised  by  his  doctor  to  break  the 
smoking  habit  because  of  probable  damage  to 
his  lungs  but  continues  to  smoke  one  to  two 
packs  of  cigarettes  a day.  He  is  the  “wise 
guy”  who  dies  of  a heart  attack  soon  after 


boasting,  “I  can  hold  two  quarts  of  liquor  and 
never  feel  it.”  He  might  well  be  the  foolish 
teenager  who  swims  in  an  almost  frozen  lake 
and  contracts  a serious  case  of  pneumonia. 
In  any  case,  the  person  who  is  indifferent 
toward  his  healthful  well-being  is  not  only 
destroying  his  own  health;  he  is  incapable  of 
accepting  the  responsibility  which  is  his 
along  with  the  blessing  of  being  an  Ameri- 
can— that  of  developing,  promoting,  and  pre- 
serving better  health  standards  for  his  great 
nation. 

The  purpose  of  these  statements  has  been 
to  inform  Americans  of  their  blessings  of 
health  and  at  the  same  time  to  present  them 
with  the  importance  of  preserving  this  God- 
bestowed  gift.  Health  has  been  discussed  as 
an  individual  problem  from  a number  of 
angles;  yet  every  statement  relates  to  the 
opening  sentence:  “Better  health  in  America 
can  never  be  created;  it  must  essentially  be 
evolved  by  the  willingness  and  determina- 
tion of  the  American  people  to  combine  their 
strength  and  knowledge  in  developing,  pro- 
moting, and  preserving  a good  health  pro- 
gram for  this  great  nation.”  Who  is  Ameri- 
ca? It  is  you  and  I;  it  is  our  parents,  our 
grandparents,  and  their  parents  before  them. 
Above  all,  it  will  be  our  children  and  their 
children  after  them.  America  belongs  to 
us;  the  preservation  of  its  health  is  in  our 
hands.  America’s  health  is  our  health — ours 
to  preserve  for  the  security  and  prosperity 
of  future  generations! 

ATHLETIC  INJURIES  CONFERENCE 

The  third  annual  conference  on  the  man- 
agement and  prevention  of  athletic  injuries, 
sponsored  jointly  by  the  Medical  Association, 
the  University  of  Alabama,  the  Alabama 
High  School  Coaches  Association,  and  the 
Alabama  High  School  Athletic  Association, 
will  be  held  at  the  University  of  Alabama  on 
August  10,  according  to  an  announcement  by 
Dr.  J.  Michaelson. 

Speakers  for  the  program  will  be  Drs.  Da- 
vid G.  Vesely,  Otis  Jordan,  Stanley  Graham, 
Richard  O.  Rutland,  Jr.,  and  Mr.  Jim  Goos- 
tree,  athletic  trainer  at  the  University  of 
Alabama. 


34 


J.  M.  A.  ALABAMA 


THE  RELATIONSHIP  OF  MEDICINE  TO 
THE  FOREIGN  POLICY  OF  THE  UNITED  STATES 


JOHN  SPARKMAN 
U.  S.  Senator 

It  has  been  suggested  that  I talk  to  you 
today  about  the  relationship  of  medicine  to 
the  foreign  policy  of  the  United  States.  I 
could  not  imagine  a more  suitable  forum  for 
discussion  of  such  a timely  and  vital  subject. 
Your  splendid  organization  is  by  no  means  a 
stranger  to  international  considerations  in 
medicine  and  health  nor  to  their  implications 
to  the  world  in  its  aspirations  for  peace. 

The  very  name  International  College  of 
Surgeons  symbolizes  the  interest,  devotion 
and  leadership  of  your  members  in  64  na- 
tions. Alabama  enjoys  a singularly  rich 
heritage  in  medicine — both  domestic  and  in- 
ternational— and  you  members  of  the  Ala- 
bama Chapter  and  the  other  members  of  the 
medical  and  health  professions  in  Alabama 
are  carrying  on  in  that  great  tradition. 

No  state  in  the  Union  is  surpassing  Ala- 
bama in  the  building  of  new  hospitals  and 
health  facilities.  These  splendidly  equipped 
public  facilities  and  private  hospitals  and 
clinics  and  nursing  facilities  are  bringing  to 
our  physicians  and  surgeons  the  tools  for 
practicing  the  modern  medicine  and  surgery 
they  know,  and  insuring  to  the  people  of 
Alabama  the  finest  in  care  and  services. 

Perhaps  the  capstone  of  your  success  is 
represented  in  your  magnificent  University 
of  Alabama  Medical  Center,  incorporating 
$17  million  worth  of  new  buildings  and  facili- 
ties already  built  and  $5  million  more  under 
construction.  This  great  medical  complex  is 


fulfilling  a wide  range  of  responsibilities  for 
education,  basic  and  clinical  research,  and 
service,  including  service  as  a referral  cen- 
ter for  all  Alabama. 

I am  told  that  there  are  today  some  700 
medical,  dental,  nursing,  intern  and  resident, 
technician,  fellow  and  graduate  students 
studying  at  your  Medical  Center.  It  is  a 
source  of  pride  that  outstanding  men  and 
women  from  many  nations  are  attracted  to 
the  Center  for  specialized  study  and  research. 

I feel  privileged  to  have  had  a part  in  the 
provision  of  programs  which  have  provided 
financial  assistance  for  this  advancement  of 
medicine,  surgery  and  medical  care  in  Ala- 
bama, such  as  the  Hill-Burton  Act,  the  Medi- 
cal Research  Construction  Act,  the  National 
Institutes  of  Health,  the  Small  Business  Loan 
Program  for  private  hospitals,  clinics,  and 
other  health  facilities,  and  the  programs  for 
nursing  homes,  college  housing  and  urban 
renewal  and  redevelopment. 

You  have  likewise  made  contributions  of 
great  consequence  to  international  medicine. 

At  the  heart  of  the  programs  of  our  gov- 
ernment in  the  area  of  international  rela- 
tions lies  the  necessity  to  establish  and  main- 
tain effective  communications  with  other  na- 
tions and  to  win  the  trust  and  confidence  of 
their  people. 

The  sympathy,  generosity  and  exceptional 
skill  of  the  American  doctor  and  surgeon  are 
legendary  throughout  the  world.  And  medi- 
cine has  been  called  the  universal  language. 
Wherever  men  talk  about  the  problems  of 
the  sick  and  disabled,  they  speak  a common 
language. 

I propose  to  present  the  proposition  that 
the  physician  and  surgeon,  the  nurse,  the 
pathologist,  the  medical  researcher  and  the 
technician  are,  in  a very  real  sense,  ambassa- 
dors and  architects  of  peace.  Their  good 
works  create  a climate  of  friendship  and 


JULY  I960— VOL.  30.  NO.  I 


35 


THE  ASSOCIATION  FORUM 


compatability.  They  lay  firm  foundations 
for  wholesome  trade  and  commercial  rela- 
tions between  other  nations  and  our  own. 

Medicine  is,  in  essence,  humanism.  Medi- 
cine, as  a social  as  well  as  a biological  science, 
comes  full  face  with  the  complexities  of  so- 
ciety. Medicine  ignores  no  essential  attri- 
bute of  man — his  nature,  his  environment,  or 
mode  of  earning  a livelihood. 

Therefore,  for  man  living  as  a member  of 
society,  public  health  becomes  an  expression 
of  his  efforts  to  prevent  disease  and  prolong 
life.  It  becomes  a foundation  for  his  aspira- 
tions for  human  dignity,  self-respect,  and 
peace  of  mind.  It  becomes  a basis  for  har- 
monious relationships  within  families,  groups 
and  communities,  and  among  nations. 

In  America,  where  doctors,  surgeons  and 
other  members  of  the  health  team  have  re- 
mained free  and  unregimented,  we  have 
electrified  the  world  by  scaling  one  new 
height  of  medical  achievement  after  another. 
Here  in  America,  where  our  people  have 
largely  been  freed  from  the  ravages  of  many 
ancient  killing  and  crippling  diseases  and 
maladies  which  are  today  the  scourges  of 
other  lands,  we  have  learned  the  worth  of 
sound  health  practices — the  worth  in  lives 
saved  and  suffering  and  disability  prevented; 
the  worth  in  the  productivity,  vigor,  general 
well-being  and  peace  of  mind  of  our  people; 
the  worth  to  the  strength  and  security  of 
our  country.  Indeed,  we  have  learned  the 
worth  to  any  people  and  to  any  land. 

Man’s  most  basic  instinct,  as  we  know,  is 
the  preservation  of  life  and  health.  In  coun- 
tries where  life  expectancy  is  half  our  own, 
where  each  year  a third  of  the  babies  die 
during  the  first  year  of  life,  one  of  the  great- 
est aids  to  American  international  relations 
is  medicine.  It  is  medicine  which  promises 
to  these  people  freedom  from  constant  suf- 
fering, greater  productivity  and  longer  life. 

Two  thousand  years  ago,  Galen  said, 
“Health  is  a sort  of  harmony.”  In  one  area 
of  the  world  after  another,  we  are  seeing  that 
health  is  not  only  a harmony  but  a har- 
monizer. 


One  illustration  is  afforded  by  the  experi- 
ence of  an  American  doctor  serving  in  a 
backward  yet  aspiring  country.  He  tells  of 
having  seen  “simple,  tender  loving  care 
change  a peoples’  fear  and  suspicion  into 
friendship  of  witnessing  the  power  of  medi- 
cal aid  to  reach  the  hearts  and  souls  of  a na- 
tion” through  ministrations  plain  people 
could  understand. 

There  is  a sentence  in  The  Education  of 
Henry  Adams  which  reads:  “A  teacher  af- 
fects eternity;  he  can  never  tell  where  his 
influence  stops.”  So  it  also  is  with  the  doc- 
tor. Let  me  cite  just  one  among  countless 
examples:  A little  peasant  boy  in  the  Tyrol 
afflicted  with  hemophilia  lost  a tooth  and 
was  literally  bleeding  to  death.  The  normal 
coagulants  could  not  save  him,  and  transfu- 
sions were  barely  keeping  him  alive.  In  Vi- 
enna, medical  people  were  contacted.  An 
American  suggested  that  only  a serum  made 
in  Michigan  would  save  him.  The  cry  for 
help  went  out.  An  Air  Force  jet  fighter 
flew  the  serum  from  Michigan  to  Westover 
Field,  Massachusetts.  From  there,  it  was 
ferried  to  Munich.  At  this  point,  a raging 
blizzard  made  the  rest  of  the  trip  extremely 
arduous  and  dangerous.  Nevertheless,  by 
plane  and  jeep,  the  serum  got  to  Innsbruck 
at  the  eleventh  hour;  and  the  little  boy  was 
saved. 

The  effect  of  this  achievement  was  spec- 
tacular. It  excited  the  imagination  and  ad- 
miration of  all  Austria,  indeed  of  Europe  it- 
self. Weighty  distinctions  between  Ameri- 
can and  Soviet  policies  suddenly  became  less 
important  than  the  instinctive  humanity  of 
the  United  States  in  throwing  its  mighty  re- 
sources into  a splendid  effort  to  save  one 
human  creature. 

Here  we  see  that  half-way  around  the 
world  and  in  a manner  far  removed  from  the 
immediate  object  of  the  research  by  the 
American  medical  scientists  who  had  devel- 
oped the  life-saving  serum,  their  influence 
had  manifested  itself  in  a diplomatic  success 
for  the  United  States. 

Admittedly,  this  was  an  exceptional  and  a 
fortuitous  event.  Diplomatic  victories  nor- 


36 


J.  M.  A.  ALABAMA 


THE  ASSOCIATION  FORUM 


mally  arise  out  of  the  conventional  and  la- 
borous  diplomatic  processes.  However,  the 
Austrian  incident  demonstrates,  first,  the 
enormous  significance  of  medical  science  in 
today’s  world;  second,  that  the  medical  pro- 
fession has  an  urgent  and  broad  role  to  play 
in  America’s  constantly  evolving  diplomacy. 

Events  at  the  ill-fated  summit  conference 
remind  us  of  how  fortunate  we  are  to  have 
had  the  vision  and  good  sense  not  to  place  all 
our  eggs  for  peace  in  the  basket  of  such  con- 
ferences. While  Mr.  Khrushchev,  in  Paris, 
was  dashing  the  hopes  of  free  men  on  the 
rock  of  threats  and  intimidation,  and  pre- 
empting public  attention  with  his  seeds  of 
discord,  another  meeting  of  wholly  different 
character  and  promise  was  taking  place  in 
Geneva.  Scarcely  noted  save  in  medical  and 
scientific  circles  and  in  the  remotest  sections 
of  the  newspapers  was  the  13th  annual  meet- 
ing of  the  World  Health  Organization,  an  in- 
strumentality of  the  United  Nations. 

On  the  one  hand,  the  Soviet  Premier  was 
doing  his  utmost  to  dis-unite,  divide  and  de- 
stroy. On  the  other  hand,  91  member-nations 
of  the  World  Health  Organization  simultane- 
ously were  welcoming  ten  new  nations  to 
membership  on  their  own  enthusiastic  peti- 
tions, bringing  the  total  membership  of  the 
World  Health  Organization  to  101  from  its 
original  63. 

These  events — contrasting  the  destructive 
and  the  positive — point  up  again  the  differ- 
ences between  the  purposes  and  methods  of 
enslaving  Communism  and  of  those  who  love 
liberty  and  who  go  quietly  about  their  plans 
for  ever  more  effective  cooperation  and  pro- 
grams for  healing  the  sick,  restoring  the  frail, 
the  halt,  and  the  blind  and  for  bringing  the 
blessings  of  freedom  and  peace  to  all  men. 

Our  American  programs  in  the  area  of  in- 
ternational medicine  and  health,  inaugurated 
and  sponsored  by  doctors,  lay  leaders,  foun- 
dations, private  companies,  universities  and 
the  government,  are  motivated  by  humani- 
tarian considerations  it  is  true.  But  each  en- 
visions reciprocal  benefits  as  it  goes  about 
making  its  own  particular  contribution  to  the 
cause  of  human  welfare  and  of  peace. 


It  is  frequently  questioned  whether  what 
we  do  abroad  is  worth  the  price.  Who  is  in 
position  to  say  that  our  expenditures  do  not 
fall  more  in  the  category  of  wise  investments 
than  of  waste? 

We  are  witnessing  returns  on  our  invest- 
ments in  a variety  of  forms — direct  and  indi- 
rect. Is  it  either  wise  or  practical  to  try  to 
measure  each  benefit  by  no  other  scale  than 
the  dollar  mark? 

The  critics  should  try  their  hands  at  plac- 
ing a dollar  value  on  a nation’s  support  of  the 
free  world  in  the  contest  against  Commu- 
nism. Has  the  price  of  strength  or  of  a 
chance  on  a winning  ticket  to  lasting  peace 
ever  been  calculated? 

What  is  the  monetary  value  of  a healthy, 
productive  mind  and  body?  The  center  of 
world  medicine  has  long  since  shifted  from 
Europe  to  the  United  States.  But  this  does 
not  mean  we  are  laying  claim  to  a complete 
monopoly  on  scientific  knowledge  and  medi- 
cal brainpower.  On  the  one  hand,  we  are 
benefactors  of  other  nations  in  many  areas  of 
medical  and  research  competencies.  But  we 
are  also  beneficiaries  of  new  techniques  and 
developments  made  available  to  us  by  re- 
searchers and  medical  people  in  other  lands. 

Can  we  compute  how  much  we  owe  to 
British  medical  scientists  for  their  basic  work 
in  cardiac  physiology  which  contributed  to  the 
ultimate  development  and  successful  use  of 
the  heart-lung  machine  that  has  made  our 
dreams  in  the  areas  of  open-heart  surgery 
and  vessel  repairing  and  transplanting  a 
reality? 

What  is  the  worth  to  us  if  we  help  less 
fortunate  nations  stamp  out  diseases  which 
once  took  a terrible  toll  in  this  country?  We 
know  we  are  never  completely  free  of  danger 
of  recurrence  or  revisitation  of  diseases. 
Sometimes  they  come  again  in  new  and  even 
more  virulent  forms. 

There  is  almost  no  limit  to  which  the  good 
businessman  will  go  to  win  a customer. 
What  is  the  worth  if  we  make  a trade  custom- 
er of  a nation  where  large  areas  of  fertile 
soil  can  neither  be  put  to  the  plow  because  of 


JULY  I960— VOL.  30,  NO.  I 


37 


THE  ASSOCIATION  FORUM 


disease,  or  where,  if  the  soil  is  planted,  crops 
rot  in  the  fields  because  disease  has  stricken 
down  those  who  would  harvest?  As  a man 
must  stand  before  he  can  walk,  so  must  a 
nation  find  its  footing  before  it  can  progress. 

No  one  contends  that  good  health  solves  all 
the  problems  of  either  human  welfare  or 
peace.  We  know  that  the  vicious  circle  of 
disease,  poverty,  discontent  and  unrest  can- 
not be  successfully  broken  by  attacking  dis- 
ease alone.  Opportunities  for  self-realization 
of  people  and  of  nations  can  be  supplied  only 
by  means  of  solid  economic  development. 

Knowledge  of  this  fact  lies  at  the  roots  of 
our  foreign  policy  and  our  participation  with 
other  countries  in  a cooperative  effort  to 
promote  economic  development  and  the  wel- 
fare of  people  and  nations. 

Just  as  the  American  medical  profession 
has  developed  successful  techniques  in 
health,  the  American  people  have  also  devel- 
oped successful  techniques  to  deal  with  other 
world  problems.  We  have  learned,  for  ex- 
ample, how  to  restore  land  and  increase  crop 
yields.  We  know  how  to  improve  teaching 
and  professional  competence  and  to  stimulate 
industrial  skills.  We  are  proficient  in  con- 
struction techniques  and  in  the  operation  of 
machines.  Such  skills  are  needed  in  the 
fight  against  starvation,  poverty  and  igno- 
rance as  much  as  the  skills  of  medicine  are 
needed  in  the  fight  against  disease. 

A large  number  of  less  developed  countries 
are  looking  to  the  west,  particularly  to  the 
United  States,  for  assistance  in  acquiring 
these  skills.  Our  aid  in  making  this  knowl- 
edge available  is  furnished  largely  through 
technical  assistance  programs.  American  ex- 
perts are  now  working  in  more  than  sixty  na- 
tions in  agriculture,  education,  public  health, 
and  many  other  fields. 

Technical  assistance,  as  you  know,  is  just 
one  part  of  our  overseas  aid.  The  less  de- 
veloped areas  are  also  badly  in  need  of  cap- 
ital for  development  of  their  material  re- 
sources; and  certain  areas,  particularly  those 
close  to  the  communist  bloc,  need  weapons 
for  defense. 


We  know  that  since  the  Mutual  Security 
Program  was  begun,  it  has  been  supported  by 
every  President,  every  Secretary  of  State, 
every  Secretary  of  Defense,  and  every  Con- 
gress. It  has  likewise  been  endorsed  by  most 
private  citizen  groups  who  have  thoroughly 
studied  it  and  by  most  of  the  major  private- 
business,  labor,  and  farm  groups.  And  yet,  in 
spite  of  this  apparent  strong  public  support, 
there  is  unmistakable  evidence  that  the  pro- 
gram is  misunderstood  and  disliked  by  large 
numbers  of  the  American  people. 

As  I see  it,  there  are  two  major  reasons  for 
the  Mutual  Security  Program:  First,  to  help 
build  up  military  strength,  in  order  to  deter 
Soviet  aggression;  and  second,  to  contribute 
to  the  economic  growth  of  the  under-devel- 
oped countries,  so  as  to  induce  a rate  of 
growth  which  promises  to  make  them  self- 
sufficient. 

Let  us  take  the  first  reason — military  as- 
sistance. It  has  been  only  too  clear  that  the 
Soviet  Union  is  prepared  to  use  force  when 
it  believes  force  will  pay  off.  Therefore,  it 
is  essential  that  we  keep  military  defenses 
strong. 

Militarily  strong  allies  are  profoundly  im- 
portant to  our  own  security.  Military  ex- 
penditures under  the  Mutual  Security  Pro- 
gram have  an  indirect  return  value  as  well. 
It  is  frequently  overlooked  that  some  90  per 
cent  of  all  expenditures  under  the  military 
assistance  program  are  spent  here  in  the 
United  States.  Also,  several  hundred  million 
dollars  worth  of  military  equipment  is  pur- 
chased from  us  each  year  by  nations  that 
once  received  military  assistance  but  are 
now  in  a position  to  pay  for  maintenance 
and  replacement  costs. 

Let  us  turn  to  the  second  point — the  neces- 
sity for  providing  economic  assistance. 

Russia  at  the  present  time  is  undertaking 
an  economic  and  political  penetration  into 
these  under-developed  countries  which  are 
the  most  vulnerable  part  of  the  free  world. 
Already  the  Sino-Soviet  Bloc  has  agreed  to 
furnish  some  four  billion  dollars  in  grants 
and  credits  to  certain  carefully  selected 
countries.  The  Bloc  has  also  given  special 


38 


J.  M.  A.  ALABAMA 


THE  ASSOCIATION  FORUM 


attention  to  enlarging  its  trade  with  these 
same  countries — and  with  marked  success.  If 
the  orientation  of  these  countries  were 
changed  and  if  they  should  become  hostile  to 
the  west,  the  area  of  the  free  world  would  be 
sharply  reduced. 

A world  situation  in  which  there  is  a 
growing  disparity  between  the  wealth  of  the 
United  States  and  the  poverty  of  the  rest 
of  the  world  is  against  the  best  interests  of 
the  United  States. 

One-and-a-quarter-billion  people  in  100 
under-developed  countries  of  the  free  world 
have  an  annual  per  capita  income  of  $100. 
The  corresponding  figure  for  the  United 
States  is  $2,100.  In  the  less  developed  coun- 
tries today  there  is  a widespread  and  deeply 
felt  resentment  against  such  disparity.  Just 
as  the  world  cannot  live  half  sick  and  half 
well,  neither  can  it  live  with  extremes  of 
poverty  and  plenty.  The  surging  populations 
of  the  “have  not”  nations,  unless  helped,  will 
soon  threaten  the  “haves.” 

In  Asia,  Africa  and  South  America,  there  is 
ferment  and  revolution.  This  is  not  just  a 
ripple  of  discontent  stirred  by  a few  Com- 
munist agitators.  This  is  a profound  stirring 
of  a vast  multitude  of  people  who  have  al- 
ways faced  poverty  and  starvation  but  who 
now  for  the  first  time  are  refusing  to  accept 
these  conditions  as  inevitable.  They  are 
seeking  economic  and  social  improvement. 
If  their  governments  offer  them  nothing  but 
continued  stagnation,  they  may  well  turn  to 
the  Communists  or  to  native  totalitarians  for 
solutions. 

But  people  turn  to  extreme  solutions  when 
there  seems  to  be  no  hope  elsewhere.  The 
purpose  of  our  aid  programs,  as  I see  it,  is  to 
provide  help  to  those  moderate  governments 
who  are  willing  to  meet  the  critical  needs  of 
these  people.  It  does  not  matter  if  economic 
progress  comes  slowly  as  measured  by  the 
economists’  charts  and  graphs.  What  mat- 
ters is  that  people  realize  that  there  is  a plan, 
a direction,  a sense  of  positive  forward  move- 
ment in  the  improvement  of  their  living 
standards.  A sense  of  economic  progress  can 
replace  despair  and  disaffection  with  hope 


and  confidence.  When  free  governments  can 
give  their  people  this  feeling  of  hope.  Com- 
munism is  defeated. 

But  let  us  measure  this  program  in  terms 
of  our  own  domestic  economy.  To  begin 
with,  about  half  of  all  expenditures  under 
the  economic  assistance  programs  are  made 
directly  in  the  United  States.  The  volume 
of  indirect  expenditures  in  the  United  States 
stemming  from  the  program  is  less  readily 
measured,  but  it  is  considerable  and  it  in- 
creases our  export  total. 

It  is  a fact  that  many  countries  are  buying 
goods  in  the  United  States  today  which  they 
could  not  conceivably  be  buying  without  the 
economic  improvement  made  possible  by 
Mutual  Security  efforts  of  the  past.  As  more 
and  more  of  the  newly  developing  countries 
achieve  expanding  economies  with  our  as- 
sistance, they  are  becoming  customers  of  the 
United  States  and  making  contributions  to 
our  own  economic  growth  through  trade  with 
American  businesses. 

We  know  how  much  foreign  trade  contrib- 
utes to  the  welfare  of  the  people  of  the  United 
States.  We  prosper  as  trade  expands  and 
suffer  as  it  contracts.  Let  us  take  the  par- 
ticular case  of  Alabama.  A recent  survey 
showed  that  exports  from  Alabama  to  14 
Latin  American  countries  represented  the 
employment  of  6,100  persons  in  our  state 
earning  $22  million  annually  in  wages  or 
farm  income.  Last  year  the  Mobile  Customs 
District  reported  exports  of  merchandise  to 
85  different  countries.  The  Netherlands  and 
Japan,  our  two  best  customers,  took  $37  bil- 
lion worth  of  our  products. 

Good  businessmen  know  that  it  takes  years 
to  establish  a solid  business  relationship, 
which  constitutes  a firm’s  most  valuable  as- 
set. Similarly,  it  takes  a long  time  to  set 
ourselves  up  in  foreign  markets.  Our  aid 
programs  begin  friendly  relations  which  can 
cast  the  die  of  future  trade  patterns. 

Most  people,  I believe,  agree  with  the 
fundamental  purposes  of  our  aid  programs. 
Opposition  is  based  primarily  on  mistakes  in 
the  administration  rather  than  on  the  policy 
involved.  Certain  critics,  however,  cite  ex- 


JULY  I960— VOL.  30,  NO.  I 


39 


THE  ASSOCIATION  FORUM 


amples  of  waste  and  maladministration  as 
reasons  for  abandoning  the  whole  enterprise. 
One  of  our  duties  on  the  Foreign  Relations 
Committee  is  to  try  to  eliminate  this  waste 
whenever  and  wherever  possible.  I am  sure 
our  efforts  in  this  respect  have  not  been  100 
per  cent  successful.  But  the  lesson  to  be 
drawn  is  that  the  program  needs  improve- 
ment which  we  are  constantly  making,  not 
dismantlement.  Waste  is  like  an  infected 
finger  which  needs  a strong  antiseptic.  We 
would  be  very  foolish  to  rid  ourselves  of  the 
infection  by  amputating  our  arm. 

You  may  recall  that  during  World  War  II, 
various  committees  of  Congress  found  in- 
stances of  waste  in  the  war  effort.  But  as 
far  as  I am  aware,  no  one  in  a position  of  re- 
sponsibility ever  concluded  from  this  that 


we  should  abandon  the  war  effort  and  ask 
Hitler  for  a separate  peace. 

The  Soviet  Union  is  not  going  to  disappear 
suddenly,  nor  are  the  less  developed  coun- 
tries going  to  become  immediately  self-sus- 
taining. These  programs  must  continue 
until  we  are  free  of  the  threat  of  Soviet  ag- 
gression and  until  the  free  world’s  population 
obtains  at  least  a minimum  basis  for  exist- 
ence so  that  they  can  become  strong  partners 
in  trade  and  can  carry  their  full  weight  in 
preserving  peace. 

Whether  we  are  motivated  by  a humani- 
tarian concern  or  from  enlightened  self-in- 
terest, we  must  evidence  a positive  willing- 
ness to  help  others.  Sharing  our  knowledge 
and  our  resources  is  the  fairest,  the  safest, 
and  the  most  practical  way  to  ensure  a peace- 
ful world. 


The  needs  of  children  were  ignored  . . . 
and  polifictd  matters  were  stressed 


I960  White  House  Conference 

THURMAN  SENSING 
Executive  Vice-President, 

Southern  States  Industrial  Council 


A lot  of  well-meaning  people,  including  the 
President  of  the  United  States,  thought  that 
a White  House  Conference  on  Children  and 
Youth  would  not  only  be  an  innocent  activity 
but  serve  a useful  purpose  as  well.  The  1960 
Conference,  held  in  Washington’s  National 
Guard  Armory  served  a purpose  all  right — 
the  purpose  of  those  individuals  and  groups 
who  want  Americans  to  be  ruled  by  a pa- 
ternalistic, socialistic  government.  One  thing 
it  certainly  was  not,  and  that  was  innocent. 
It  was  a cleverly  staged  production,  designed 
to  promote  big  government,  in  which  many  of 


the  adult  and  youth  delegates  were  dupes. 

The  White  House  Conference  was  instruc- 
tive in  that  it  revealed  how  radical  groups, 
who  are  utterly  opposed  to  states  rights  and 
local  authority,  can  stage  a show  to  further 
their  objectives.  The  7,000  delegates  ob- 
viously couldn’t  hold  any  truly  free  discus- 
sions on  the  real  problems  confronting  Amer- 
ican youth — such  as  how  to  retain  independ- 
ence from  big  government — because  the 
managers  of  the  Conference  had  control  of 
the  agenda.  Those  delegates  who  had  ideas 
that  departed  from  the  “liberal”  line  found 


40 


J.  M.  A.  ALABAMA 


THE  ASSOCIATION  FORUM 


that  they  were  not  encouraged  to  speak  up 
and  challenge  the  prevailing  orthodoxy. 
Twenty-six  resolutions  were  adopted  without 
any  discussion  whatsoever.  As  to  how  many 
independent  souls  were  present  at  the  Con- 
ference, no  one  will  ever  know.  But  it  is 
doubtful  that  the  list  of  them  would  have 
had  many  names  on  it.  Reporters  as  yet 
have  not  been  able  to  discover  the  system 
under  which  individual  delegates  and  vari- 
ous organizations  were  asked  to  take  part. 
Conservative  groups  that  stress  patriotism 
and  defense  of  a free  economy  had  no  part 
in  the  proceedings. 

As  to  the  Conference  being  dedicated  to  the 
problems  of  children  and  youth,  that  was  the 
biggest  sham.  The  real  objective,  obviously, 
was  to  get  an  endorsement  for  various  radical 
schemes  in  the  name  of  American  youth.  The 
fact  that  the  Conference  was  a “White 
House”  conference  made  it  especially  valua- 
ble to  its  managers,  for  it  enabled  them  to 
attach  the  prestige  of  the  Presidency  to  pro- 
posals that  the  President  himself  would  not 
endorse.  Without  the  managers  and  their 
objectives  being  checked,  the  lending  of  the 
“White  House”  name  to  the  Conference  hurt 
the  very  conservatism  on  financial  and  other 
issues  that  the  President  had  advocated  while 
in  office. 

Checking  of  the  program  objectives  would 
have  paid  off  for  both  the  President  and  the 
country.  Surely  the  President  must  have 
been  appalled  when  be  learned  that  Pauline 
Frederick,  a news  commentator  for  the  Na- 
tional Broadcasting  Company,  is  reported  to 
have  told  the  delegates  that  it  would  be  bet- 
ter for  the  money  the  nation  spends  on  mis- 
siles and  nuclear-powered  submarines  to  be 
put  into  such  things  as  schools  and  wheat  for 
various  nations  in  Asia  and  Africa.  The 
tragedy  of  the  Conference  is  that  no  one  had 
the  courage  to  stand  up  and  tell  Miss  Fred- 
erick that  her  statement  was  an  insult  to  all 
thinking  persons  who  know  that  the  armed 
forces  are  essential  protection  against  com- 
munist aggression.  It  is  shameful  that  im- 
pressionable young  people  should  return  to 
their  homes  with  the  idea  planted  in  their 
minds  that  it  is  wrong  for  the  United  States 


to  spend  money  for  its  own  safety  in  this 
age  of  Red  tyranny. 

It  was  equally  outrageous  that  the  “child 
experts”  should  endorse  a civil  disobedience 
campaign  in  this  country.  If  young  people 
are  encouraged  to  think  that  they  have  a 
right  to  invade  a businessman’s  property 
and  remain  there  in  violation  of  trespass 
laws,  after  being  requested  to  leave,  what 
will  be  their  faith  in  private  property?  And 
if  the  mass  sit-in  demonstration  is  endorsed 
as  a legitimate  social  protest  weapon,  where 
will  use  of  this  weapon  lead?  The  youngster 
who  is  convinced  he  has  a right  to  stay  in  a 
store  when  ordered  out  may  conclude  that 
he  can  also  invade  other  property.  Leftwing- 
ers may  next  encourage  sit-in  demonstrations 
in  courts,  for  example.  Those  persons  who 
disapproved  of  California’s  handling  of  the 
Chessman  case  might,  under  the  sit-in  theory 
endorsed  at  the  Conference,  have  invaded 
state  courts  in  California  and  refused  to  move 
until  a judge  granted  the  convicted  sex  ter- 
rorist a stay  of  execution.  This  technique  is 
straight  from  the  communist  book  of  social 
protest,  and  to  put  approval  of  it  in  the 
“mouths  of  babes”  was  a vicious  thing. 

Equally  objectionable  was  the  suggestion 
of  William  G.  Carr,  executive  secretary  of 
the  National  Education  Association,  that  the 
Conference  delegates  might  well  march  down 
to  the  Capitol  and  tell  their  representatives 
to  vote  for  more  federal  spending.  For- 
tunately, that  march  never  took  place.  But 
this  and  other  techniques  of  protest  approved 
at  the  Conference  sound  like  tactics  used  by 
revolution-torn  Latin  American  countries. 
In  the  United  States,  responsible  citizens 
don’t  usually  stage  protest  marches  on  the 
national  legislature. 

America  and  its  policies  were  considered 
fair  game  at  the  Conference.  The  Rev.  Philip 
Potter  of  Geneva,  Switzerland,  an  official  of 
the  World  Council  of  Churches,  condemned 
various  aspects  of  the  American  way  of  life. 
He  criticized  the  delegates  for  not  discussing 
more  world  problems.  The  fact  that  Ameri- 
can young  people  ought  to  think  first  about 
their  nation  seemed  not  to  have  occurred  to 


JULY  I960— VOL.  30,  NO.  I 


41 


THE  ASSOCIATION  FORUM 


him.  Actually,  this  sort  of  political  inter- 
ference in  the  domestic  affairs  of  the  United 
States  is  a violation  of  the  historic  principle 
of  the  separation  of  church  and  state.  This 
was  another  occasion  when  some  brave  soul 
should  have  risen  in  his  seat  to  say  that  the 
problems  of  childen  and  youth  in  the  United 
States  are  not  the  business  of  a foreign-based 
clergyman.  He  shouldn’t  have  presumed  to 
tell  them  how  they  should  live  and  how  the 
United  States  should  conduct  itself. 

The  needs  of  children  were  ignored,  and 
political  matters  were  stressed.  Certainly, 
advocacy  in  the  Conference  of  a new  federal 
minimum  wage  law  isn’t  a “children’s”  issue. 
Neither  is  the  issue  of  birth  control,  which 
came  in  for  discussion.  That  is  an  issue  well 
left  alone  to  individual  parents  and  to  the 
various  religious  denominations.  A national 
youth  conference  conducted  under  the  aus- 
pices of  the  “White  House”  should  stay  away 
from  that  subject.  As  for  endorsing  federal 
aid  to  education  on  a colossal  scale,  that  was 
100  per  cent  politics. 

The  entire  Conference  was  riddled  with 
socialistic  ideas.  There  was  talk  of  a child 
“rights  bill,”  a piece  of  jargon  employed  by 
groups  that  want  the  state  to  usurp  the  au- 
thority of  the  family.  Another  discussion 
centered  on  international  youth  camps  to 
“properly  condition  problem  children.”  One 
speaker  made  this  statement:  “If  we  are  to 
socialize  the  child,  we  must  release  him, 
earlier  and  earlier,  from  the  nuclear  family 
(father  and  mother)  to  the  larger  family 
(the  state).”  Some  of  the  “experts”  also  an- 
nounced in  one  discussion  that  a mother  and 
father  joined  in  wedlock  is  no  longer  the 
“normal  family.”  Yet  another  speaker  ques- 
tioned the  rightness  of  allowing  successful 
business  men  to  teach  Sunday  school  classes. 
He  charged  that  it  is  bad  to  follow  “certain 
ritualistic  practices”  such  as  “praying  before 
a business  deal,  and  calling  on  God  to  give 
them  insight  enough  to  outsmart  the  other 
fellow.” 

It  is  clear  that  the  Conference  bore  down 
heavily  on  the  American  family,  the  Ameri- 
can free  economy,  and  American  resistance 


to  overseas  threats.  The  adults  and  young 
people  in  attendance  were  urged  to  believe 
that  good  citizenry  consists  of  engaging  in 
mass  protests  against  unpopular  laws  and 
customs  and  spending  huge  sums  of  the  peo- 
ple’s money  on  schools  (the  “progressive” 
kind)  and  on  foreign  aid.  If  the  delegates 
preach  in  their  home  communities  and  in- 
stitutions what  they  heard  at  the  1960  White 
House  Conference  on  Children  and  Youth, 
the  United  States  will  have  been  dealt  a 
blow.  Indeed  the  various  suggestions  ad- 
vanced at  the  Conference  dovetail  neatly 
with  the  propaganda  and  agitation  objectives 
of  this  nation’s  enemies.  Weakening  of  the 
American  home  and  free  enterprise  are  ma- 
jor objectives  of  all  who  hate  the  United 
States. 

The  sickening  fact  about  this  Conference, 
which  was  so  hurtful  to  American  interests, 
is  that  it  was  financed  by  the  taxpayers 
themselves.  Congress  appropriated  $250,000 
and  the  federal  government  allotted  another 
$100,000  it  had  on  hand.  Many  of  the  dele- 
gates attended  the  conference  on  funds  sup- 
plied by  state  institutions  and  agencies.  As 
is  true  of  so  many  radical  campaigns,  the 
public  paid  for  its  own  undoing. 

If  one  had  to  give  a single-phrase  descrip- 
tion of  the  1960  White  House  Conference  on 
Children  and  Youth,  the  best  phrase  would 
be  disarmament  conference — moral  disarma- 
ment, that  is.  By  persuading  the  young  peo- 
ple of  this  nation  that  socialist  programs  are 
good  for  both  individual  and  nation,  the 
Conference  managers  were  disarming  their 
fellow  citizens  when  they  need  all  their 
strength  to  resist  subversion  at  home  and 
aggression  abroad. 

WEIGHT-WATCHERS 

Too  many  weight-watchers  are  scared  off 
by  the  lack  of  “crash”  results  in  exercise. 
They  realize,  for  instance,  that  it  takes  seven 
hours  of  log  chopping  to  lose  a single  pound. 
However,  going  at  it  for  only  half  and  hour 
every  day  would  lead  to  the  loss  of  about  two 
pounds  in  a month  or  twenty-six  in  a year. — 
Nutrition  Items,  Vol.  II,  No.  28,  1959. 


42 


J.  M.  A.  ALABAMA 


,1 


[EN — President  and  Mrs.  E.  V. 
(right)  and  Dr.  and  Mrs.  Elbert 
s,  S'r.,  greeted  their  many  friends  at 
hour  prior  to  the  banquet. 


SENATOR — J o h n Sparkman 
banquet  speaker  at  the  annual 
of  the  Alabama  Section  of  the 
mal  College  of  Surgeons  in  Tus- 
n May  26.  Pictured  with  Sena- 
kman  are  (left  to  right)  Drs. 
jy  and  Otis  Jordan, 


HOTEL  STAFFORD — Tuscaloosa’s  newest  hotel,  proved 
to  be  the  ideal  setting  for  I.  C.  S.’s  annual  banquet. 


PROGRAM  SPEAKER— Dr.  Robert  J.  Meade  (right)  of  Nevi  | 
Orleans  is  shown  discussing  certain  aspects  of  his  paper,  “Im4| 
mediate  or  Delayed  Repair  of  Injuries”,  with  Dr.  and  Mrs.  wj| 
H.  Irwin  (center)  and  Dr.  Albert  Jackson  (left). 


OL-Qif,  4t  Suti*<no,iuun 

One  of  the  highlights  of  the  21st  Postgraduate  Educational  Seminar 
of  the  Alabama  Academy  of  General  Practice  in  Mobile  on  August  24- 
25  will  be  a symposium  on  obstetrics  and  gynecology.  Speakers  for  the 
symposium  will  be  (clockwise)  Drs.  Julian  P.  Hardy,  L.  Clark  Grav- 
lee,  Jr.,  Herbert  H.  Thomas,  and  Harry  Goldner. 


MYELOMA  STUDY — Two  experimental  coun- 
terparts of  multiple  myeloma,  a deadly  and  rapidly 
progressing  form  of  cancer,  are  being  studied  here 
at  the  Medical  Center  through  mouse-myeloma 
colonies  started  by  Ralph  F.  Coleman.  The  medi- 
cal student-NIH  fellow  is  shown  here  in  a patholo- 
gy department  laboratory  with  Mrs.  Erin  Sullivan, 
lab  assistant. 


MULTIPLE  MYELOMA  RESEARCH 
BEING  CONDUCTED  HERE 


Answers  to  some  of  the  perplexing  ques- 
tions concerning  a deadly  and  particularly 
rapid  form  of  cancer  may  be  found  at  the 
Medical  Center  through  a program  which  has 
developed  from  a medical  student’s  post- 
sophomore research  fellowship  project. 

Multiple  myeloma,  or  plasma  cell  leuke- 
mia, is  the  disease  under  attack — a type  of 
cancer  which  usually  kills  within  21  months 
after  diagnosis.  Until  recently,  investiga- 
tions of  this  disease  were  seriously  hampered 
by  the  fact  that  there  was  no  experimental 
counterpart  for  the  condition. 

Then  plasma  cell  tumors  closely  related  to 
myeloma  were  found  in  several  strains  of 


mice;  and,  by  inbreeding  the  animals,  scien- 
tists were  able  to  transplant  the  cancerous 
tissue  into  healthy  animals  and  thus  keep 
these  tumors  alive  for  research  purposes. 

Last  summer,  Ralph  F.  Coleman  who  had 
started  an  NIH  postsophomore  fellowship  in 
July  and  Dr.  William  J.  Hammack  of  the  de- 
partment of  medicine  visited  the  National 
Cancer  Institute  to  learn  some  of  the  tech- 
niques being  used  to  study  plasma  cell  tu- 
mors in  mice.  While  there  they  conferred 
with  Dr.  Thelma  D.  Dunn,  a leading  investi- 
gator in  this  field,  and  were  supplied  by  Dr. 
Dunn  with  mice  carrying  two  types  of 
myeloma-like  tumor.  Mr.  Coleman  subse- 
quently used  these  animals  to  establish  two 
mouse-myeloma  colonies  at  the  Medical  Cen- 
ter, making  this  one  of  the  first  institutions 
in  the  country,  outside  of  NIH,  to  have  an 
active  research  program  with  these  particu- 
lar tumors. 

Availability  of  an  experimental  prototype 
for  multiple  myeloma  excited  a great  deal 
of  interest  here  among  investigators  previ- 
ously involved  in  research  relating  to  leuke- 
mia and  other  kinds  of  cancer.  Some  of  these 
scientists  formed  a Mouse  Myeloma  Confer- 
ence in  the  hope  that  collaboration  and  mu- 
tual assistance  among  those  working  with 
experimental  myeloma  might  advance  indi- 
vidual projects  and  strengthen  the  overall 
program  in  this  field. 

On  the  conference  committee  are  Dr.  J.  F. 
A.  McManus,  professor  and  chairman  of 
pathology;  Dr.  Walter  B.  Frommeyer,  Jr., 
professor  and  chairman  of  medicine;  Dr. 
Charles  H.  Lupton,  Jr.,  associate  professor  of 
pathology;  Dr.  Marshall  W.  Hartley,  instruc- 
tor in  anatomy  and  pathology;  Dr.  Charles  O. 
Hathaway,  research  associate  in  pathology; 
Dr.  Hammack  and  Mr.  Coleman. 


JULY  I960— VOL.  30,  NO.  I 


45 


MEDICAL  CENTER  NEWS 


The  student  fellow  set  up  his  own  research 
projects  in  the  department  of  pathology 
under  the  direction  of  Dr.  McManus.  In  one 
of  the  myeloma  colonies  40  per  cent  of  the 
tumor-bearing  animals  developed  kidney 
lesions  very  similar  to  those  which  cause 
death  from  renal  failure  in  about  43  per  cent 
of  humans  with  multiple  myeloma.  Mr. 
Coleman  has  studied  these  lesions  intensively 
during  the  past  year,  and  they  were  first 
described  in  detail  in  his  thesis  for  the  mas- 
ter’s degree  which  he  received  in  May. 

In  collaboration  with  Drs.  Hammack  and 
Frommeyer,  he  has  carried  on  studies  con- 
cerning the  occurrence  of  abnormal  serum 
and  urinary  proteins  in  the  tumor-bearing 
mice;  and  he  and  Dr.  Hartley  have  engaged 
in  electron  microscopic  examination  of  the 
tumors  and  their  lesions. 

Other  projects  under  way  deal  with  fac- 
tors concerning  the  cancer’s  origin.  Accord- 
ing to  Mr.  Coleman,  there  is  strong  presump- 
tive evidence  of  a viral  etiology  for  the  dis- 
ease and  definite  indication  that  real  prog- 
ress in  this  area  may  be  made  in  the  near 
future. 

Although  Mr.  Coleman’s  active  participa- 
tion in  this  research  will  be  limited  when  he 
resumes  his  medical  school  work  this  fall, 
additional  support  from  the  NIH  is  expected 
to  make  possible  the  continuation  of  several 
studies  aimed  at  determining  what  factors 
are  required  to  produce  renal  lesions  in 
mouse  myeloma.  Information  thus  gained 
may  help  solve  the  mystery  concerning  simi- 
lar lesions  in  man. 

With  pathology  faculty  members  directing 
the  overall  program  in  this  department,  a 
small  research  team  will  carry  on  investiga- 
tions currently  being  planned  for  the  imme- 
diate future.  James  Marshall  of  Birmingham 
and  David  Russell  of  Frederick,  Okla.,  both 
dental  students  who  have  NIH  postsopho- 
more fellowships  in  pathology,  are  to  be 
working  on  these  projects,  along  with  Mrs. 
Erin  Sullivan,  a full-time  laboratory  assist- 
ant, and  Mrs.  Delores  Madden,  who  will 
assist  with  special  histochemical  procedures. 


Winner  of  the  Stuart  Graves  Pathology 
Award  in  1959,  Mr.  Coleman  is  a member  of 
Alpha  Omega  Alpha,  honorary  scholastic  so- 
ciety for  students  in  medicine,  and  a number 
of  other  professional  organizations,  includ- 
ing  Sigma  Xi,  to  which  he  was  recently 
elected  as  an  associate  member.  He  is  also 
president  of  Phi  Beta  Pi  Fraternity  here  and 
serves  as  student  editor  of  the  group’s  na- 
tional publication.  A native  of  Jacksonville, 
Mr.  Coleman  is  married  to  the  former  Eliza- 
beth Jane  Zook,  who  recently  completed  her 
freshman  year  in  the  Medical  College. 


SIGMA  XI  ELECTS  NEW  OFFICERS 


Members  of  the  Medical  Center  Chapter  of 
Sigma  Xi  installed  officers  for  the  coming 
year  and  welcomed  16  new  members  at  a 
banquet  in  May. 

Dr.  E.  Carl  Sensenig,  professor  of  anato- 
my and  chairman  of  the  department,  became 
president  of  the  group,  succeeding  Dr.  Robert 
W.  Mowry,  professor  of  pathology.  Dr.  Mow- 
ry  spoke  on  “The  Waste  of  Uncommunicative 
Discovery”  at  the  meeting. 

Other  1960-61  officers  are  Dr.  Glenn  J. 
Dixon  of  Southern  Research  Institute,  vice- 
president;  Dr.  Sidney  P.  Kent,  associate  pro- 
fessor of  pathology,  secretary;  Dr.  Robert  W. 
Longley,  assistant  professor  of  biochemistry, 
treasurer;  and  Dr.  John  M.  Bruhn,  professor 
of  physiology  and  chairman  of  the  depart- 
ment, archivist. 

Elected  to  full  membership  in  the  scientific 
honor  society  were  Dr.  William  J.  Barrett, 
Southern  Research  Institute;  Dr.  Buris  R. 
Boshell,  assistant  professor  of  medicine;  Dr. 
Margaret  Klapper,  assistant  professor  of 
medicine  and  associate  professor  of  clinical 
dentistry;  Raymond  H.  Lindsay,  graduate 
student  in  pharmacology;  Dr.  Thomas  F. 
Paine,  professor  of  microbiology  and  chair- 
man of  the  department;  Dr.  Constance  Pitt- 
man, senior  assistant  resident  in  the  depart- 
ment of  medicine;  Dr.  James  A.  Pittman,  as- 


46 


J.  M.  A.  ALABAMA 


MEDICAL  CENTER  NEWS 


sistant  professor  of  medicine;  N.  Sheldon 
Skinner,  medical  student;  Dr.  Ryo  Tanaka, 
Fulbright  fellow  in  the  department  of  physi- 
ology, and  Dr.  Adeeb  E.  Thomas,  professor 
of  dentistry. 

New  associate  members  are  Ralph  F.  Cole- 
man, medical  student;  John  M.  Shackleford, 
graduate  student  and  teaching  assistant  in 
the  department  of  anatomy;  Stitaya  Sirisin- 
ha,  graduate  and  dental  student,  and  R.  D. 
Yates,  graduate  student  and  teaching  assist- 
ant in  the  department  of  anatomy. 

Dr.  Granville  W.  Larimore,  New  York 
State  Department  of  Health,  and  Dr.  Robert 
P.  McBurney,  University  of  Tennessee  School 
of  Medicine,  were  elected  as  members.  Both 
are  graduates  of  the  Medical  College  of  Ala- 
bama. 


DR.  J.  F.  A.  MCMANUS 


PATHOLOGIST  TO  DO  CELL  RESEARCH 
AT  OXFORD 


Dr.  J.  F.  A.  McManus,  professor  of  patholo- 
gy and  chairman  of  the  department,  has  been 
granted  a year’s  leave-of-absence  to  do  his- 
tochemical  research  in  the  area  of  cell  divi- 
sion at  Oxford  University  in  England. 


Dr.  McManus  will  be  working  in  the  de- 
partment of  zoology  and  comparative  anato- 
my at  the  University  Museum,  Oxford,  where 
he  spent  a year  as  Beit  Memorial  Fellow  in 
Medical  Research  in  1945-46. 

A grant  from  the  Commonwealth  Fund  of 
New  York  makes  possible  this  sabbatical 
leave,  according  to  Dr.  McManus.  The  Com- 
monwealth Fund  awards  these  fellowships  to 
individuals  of  senior  academic  standing  to 
enable  them  to  spend  time  in  research,  writ- 
ing, and  advanced  study  which  will  enhance 
their  stature  as  teachers. 

During  Dr.  McManus’  absence,  a visiting 
pathologist  from  the  Royal  College  of  Sur- 
geons, London,  will  aid  in  carrying  out  the 
teaching  and  research  functions  of  the  de- 
partment. Administrative  duties  will  be 
taken  over  by  Dr.  Charles  H.  Lupton,  Jr., 
associate  professor  of  pathology,  who  will  be 
acting  chairman. 

While  abroad  Dr.  McManus  will  be  a speak- 
er at  meetings  of  the  International  Congress 
of  Medicine  in  Basel,  Switzerland,  and  the 
International  Congress  of  Histochemistry  in 
Paris.  He  plans  to  visit  Spain  and  Italy  dur- 
ing the  year. 

Dr.  John  L.  Pead,  lecturer  in  pathology  at 
the  Royal  College  of  Surgeons,  will  assume 
the  duties  of  a visiting  professor  on  August 
1 and  will  remain  throughout  the  academic 
year. 

Dr.  McManus  has  been  professor  and  chair- 
man of  pathology  since  1953.  He  earlier  had 
served  for  four  years  as  assistant  professor 
and  associate  professor  in  the  same  depart- 
ment, leaving  in  1950  to  become  associate 
professor  of  pathology  at  the  University  of 
Virginia. 

Educated  at  Fordham  University  and  hav- 
ing received  his  medical  degree  from  Queen’s 
College  in  Canada,  Dr.  McManus  was  a resi- 
dent pathologist  at  Johns  Hopkins  and  New 
York  Hospital  before  joining  the  Medical 
Center  faculty. 


JULY  I960— VOL.  30,  NO.  I 


47 


OUTSTANDING  DENTAL  STUDENTS 
HONORED 


Awards  for  superior  achievement  in  dental 
study  were  presented  to  18  students  in  the 
School  of  Dentistry  during  a special  honors 
convocation  recently.  The  program  at  Lib- 
erty National  Life  Auditorium  was  followed 
by  a reception  at  the  Medical  Center  for  stu- 
dents, their  families,  and  other  guests. 

Five  seniors  were  tapped  for  Omnicron 
Kappa  Upsilon,  national  honorary  dental 
fraternity.  They  were  Billy  Ervin  Hagan, 
Foley;  Joseph  Thomas  Roberts,  Alexander 
City;  John  Allen  Smith,  Chunchula;  Bryant 
Gordon  Speed,  Fairhope;  and  Alex  David 
Trum,  Jr.,  Montgomery. 

Bryant  Speed  was  also  named  as  winner 
of  the  Alpha  Omega  Scholarship  Award  for 
the  highest  scholastic  average  during  four 
years  of  dental  studies  and  as  a candidate  for 
graduation  with  honors  under  the  special 
Honors  Program.  Other  seniors  in  the  Hon- 
ors Progi’am  are  John  William  Bolt,  Birming- 
ham; Charles  Brunson,  Jr.,  Andalusia;  and 
Glen  Edward  Robinson,  Birmingham. 

Announced  as  members  of  Omicron  Delta 
Kappa,  national  leadership  fraternity,  were 
Bryant  Speed  and  Henry  Paul  Hufham,  Jr., 
Eufaula. 

Charles  Brunson,  Jr.  won  the  American 
Academy  of  Dental  Medicine  Award,  and 
William  Huston  McLendon  of  Birmingham 
received  the  American  Society  of  Dentistry 
for  Children  Award. 

Winners  for  presentations  at  the  annual 
Clinic  Day  sponsored  by  OKU  were  William 
Max  McDonald,  Geneva,  and  Jack  Milton 
Osburne,  Birmingham,  first  place;  Frank 
Meriwether  Mathews,  Montgomery,  and  Joe 
Ross  Pullen,  Huntsville,  both  juniors,  second 
place;  Richard  Inge  Finch,  Mobile,  fourth 
place;  and  Chester  Haynes  Swindle  and  Don- 
ald Richard  McNeal,  both  of  Birmingham, 
and  Glen  Edward  Robinson,  fifth  place. 

Dr.  Tinsley  R.  Harrison,  professor  of  medi- 
cine, was  convocation  speaker. 


NEW  RESEARCH  AID— Dr.  Mervyn  B.Quigley 
looks  over  the  electron  microscope  recently  in- 
stalled in  his  laboratory.  This  is  the  second  elec- 
tron scope  to  be  installed  at  the  Medical  Center. 


MEDICAL  CENTER  GETS  SECOND 
ELECTRON  SCOPE 


The  Medical  Center’s  second  electron  mi- 
croscope— a Philips  EM  75 — was  recently  in- 
stalled in  the  laboratory  of  Dr.  Mervyn  B. 
Quigley  in  the  Research  Building. 

The  new  13  thousand  dollar  instrument 
achieves  resolution  of  35  angstroms  or  better 
under  normal  working  conditions  (one 
angstrom  equals  1/10,000  of  a micron,  or 
1/10,000,000  of  a millimeter)  and  gets  a pri- 
mary magnification  of  up  to  12,000  diameters. 
The  scope  has  a front-end  camera,  and  sec- 
ondary photographic  enlargement  makes  it 
possible  to  view  the  subject  under  study  at 
far  gi'eater  magnification  than  the  primary 
enlargement  affords. 

These  limits  of  resolution  and  magnifica- 
tion mean  that  the  electron  microscope  can 
reveal  details  of  intracellular  structure — an 
important  point  in  the  research  work  for 
which  Dr.  Quigley  will  use  it.  An  NIH 
senior  research  fellow  as  well  as  assistant 
professor  of  dentistry  and  instructor  in 


48 


J.  M.  A.  ALABAMA 


MEDICAL  CENTER  NEWS 


anatomy,  Dr.  Quigley  is  engaged  in  a study  of 
such  oral  problems  as  replica  study  of  tooth 
surface  and  development  and  calcification  of 
teeth.  An  electron  microscope  is  required  to 
make  visible  the  intracellular  structures 
which  function  to  form  the  proteins  that  be- 
gin tooth  development. 

Also  important  in  Dr.  Quigley’s  work  is 
the  ability  of  the  new  scope  to  identify  spe- 
cific minerals  through  electron  defraction, 
achieved  by  special  adjustments  of  the  in- 
strument. 

The  Medical  Center’s  other  electron  scope 
is  located  in  the  anatomy  department  labora- 
tory directed  by  Dr.  Marshall  W.  Hartley,  in- 
structor in  anatomy  and  pathology. 

DR.  SHERMAN  C.  RAFFEL 
RECEIVES  SREB  GRANT 

Dr.  Sherman  C.  Raffel,  assistant  professor 
of  clinical  psychology,  has  received  a $270.00 
in-service  training  grant  from  the  Southern 
Regional  Education  Board  under  its  program 
in  mental  health  training  and  research. 

Dr.  Raffel  will  visit  the  department  of 
neurosurgery  at  the  Indiana  University  Med- 
ical Center  to  study  operations  and  programs 
at  that  institution. 

The  SREB  in-service  training  grants  were 
made  possible  by  a $90,000  grant  for  this  pur- 
pose by  the  National  Institute  of  Mental 
Health.  They  are  designed  to  enable  staff 
members  of  mental  hospitals  or  training 
schools  in  the  south  to  observe  new  or  un- 
usual programs  in  other  hospitals  anywhere 
in  the  country  to  help  them  improve  their 
own  programs. 

Applications  for  grants  are  still  being  ac- 
cepted by  SREB.  There  is  no  deadline,  and 
applications  are  acted  upon  as  they  are  re- 
ceived. Persons  interested  in  the  grants 
should  write  directly  to  the  Southern  Re- 
gional Education  Board  in  Atlanta. 

N.D.E.A.  FELLOWSHIPS  GO  TO 
ALABAMA  STUDENTS 

Twenty-five  graduate  students  at  Alabama 
and  Auburn  Universities  have  been  awarded 
fellowships  to  study  under  the  National  De- 


fense Education  Act  sponsored  by  Senator 
Lister  Hill  in  the  85th  Congress. 

U.  S.  Commissioner  of  Education  Lawrence 
G.  Derthick  has  informed  the  senior  Alabama 
Senator  that  the  Alabama  awards  are  among 
nearly  1,500  such  graduate  fellowships  being 
made  under  the  National  Defense  Education 
Act  and  starting  in  the  1960-61  academic  year. 

“The  purpose  of  the  fellowship  program 
provided  under  Title  IV  of  the  National  De- 
fense Education  Act  is  to  help  promising 
students  to  prepare  themselves  for  college 
teaching  careers  and  thus  to  insure  that  our 
nation  will  have  available  the  scientists,  en- 
gineers and  other  technically  trained  people 
that  we  need  to  meet  the  demands  of  national 
security,”  according  to  Senator  Hill. 

Each  fellow  receives  $2,000  in  the  first 
year,  $2,200  in  the  second  year  and  $2,400  in 
the  third  year,  together  with  an  allowance  of 
$400  per  year  for  each  dependent.  The  in- 
stitutions receive  up  to  $2,500  per  year  for 
each  fellow. 

In  addition  to  the  25  students  awarded 
N.D.E.A.  Fellowships  at  the  two  Alabama 
Universities,  a number  of  Alabama  students 
attending  out-of-state  schools  are  listed 
among  those  receiving  awards. 


lOOtl) 

Annual  ^egiSion 

of  the 

Medical  Association 
of  the 

State  of  Alabama 

Hotel  Stafford 
Tuscaloosa 

April  27-29 
1961 


JULY  1960— VOL.  30,  NO.  I 


49 


STATE  DEPARTMENT  OF  HEALTH 


BUREAU  OF  ADMINISTRATION 

D.  G.  Gill,  M.  D. 

State  Health  Officer 


A NEW  APPROACH  TO  TUBERCULOSIS 
CASE-FINDING 

(Based  on  a paper  prepared  by  W.  H.  Y. 
Smith,  M.  D.,  for  presentation  at  the  annual 
meeting  of  the  Alabama  Public  Health  Asso- 
ciation.) 

The  mass  X-ray  approach  to  tuberculosis 
case-finding  has  been  in  use  in  Alabama  since 
1947.  During  these  years,  it  has  been  an  ef- 
fective weapon  in  discovering  new  cases  of 
tuberculosis.  In  1948,  for  example,  333  cases 
were  found  through  mass  survey.  Recently, 
however,  this  method  has  not  been  as  pro- 
ductive, only  95  cases  being  discovered  in 
1959.  Therefore,  a new  method  of  case-find- 
ing has  been  devised.  This  new  method  will 
consist  of  spot  X-ray  testing  and  cluster  test- 
ing among  the  general  population  and  tuber- 
culin testing  of  all  individuals  thirteen  years 
of  age  and  younger. 

This  is  a refinement  of  technic  in  that  case- 
finding efforts  will  be  directed  toward  known 
areas  of  prevalence  rather  than  toward  the 
population  at  large.  The  new  method  will  re- 
quire that  a map  be  maintained  for  each 
county  showing  the  location  of  each  case  of 
tuberculosis  reported  since  January  1,  1960. 
These  maps  will  indicate  high  prevalence 
areas,  areas  where  a few  cases  are  grouped 
and  isolated  cases  which  may  constitute  the 
beginning  of  a focus  of  infection. 

For  the  isolated  cases,  the  clustering  tech- 
nic would  be  the  method  of  choice.  Here,  the 
patient  would  be  interviewed  to  identify  his 
direct  contacts,  intimate  relatives  and  friends. 
These  contacts  would  be  referred  to  the  local 
health  department.  Contacts  who  are  14 
years  of  age  and  over  would  be  screened  by 


70  mm.  X-rays.  Those  who  are  under  14  years 
of  age  would  be  tuberculin  tested. 

Areas  in  which  a few  cases  are  grouped 
might  be  investigated  by  cluster  testing  only 
or  by  a combination  of  cluster  and  spot  test- 
ing. Spot  testing  is  a type  of  pin-point  mass 
testing  in  which  older  persons  in  a given  lim- 
ited area  would  be  X-rayed  and  the  younger 
ones  (under  14)  tuberculin  tested. 

In  high  prevalence  areas,  both  spot  and 
cluster  testing  would  be  necessary.  The  lat- 
ter type  of  testing  is  necessary  to  be  sure  that 
intimate  relatives  and  friends  who  may  live 
outside  the  area  of  spot  testing  are  not  over- 
looked. 

Under  this  new  method,  when  an  area  is 
selected  for  X-ray  work,  clearance  will  be 
made  with  the  County  Medical  Society  and 
the  County  Health  Officer.  An  X-ray  tech- 
nician will  then  take  a mobile  unit  to  the 
county  health  department.  Adult  contacts 
will  be  asked  to  come  in  to  have  X-rays  made. 
On  the  same  date,  the  contacts  who  are  under 
14  will  be  tuberculin  tested.  The  tuberculin 
test  is  administered  and  interpreted  by  a phy- 
sician or  nurse. 

If  this  primary  method  of  case-finding  is 
to  be  successful,  the  secondary  or  diagnostic 
clinic  must  be  streamlined,  too.  It  is,  there- 
fore, planned  that  this  secondary  clinic  would 
be  held  two  to  three  weeks  later.  At  that 
time,  all  individuals  with  suspicious  readings 
from  70  mm  X-ray  films  and  tuberculin  test- 
ing would  have  a 14  x 17  film  made.  This 
timing  is  based  on  the  premise  that  films 
taken  one  week  could  be  developed  and  read 
the  following  week.  At  least  one  more  week 
would  be  needed  to  notify  individuals  who 


50 


J.  M.  A.  ALABAMA 


DEPARTMENT  OF  HEALTH 


would  be  asked  to  come  back  for  the  14  x 17 
film.  Those  suspects  who  need  a continuing 
follow-up  would  be  referred  to  the  routine 
diagnostic  clinics. 

This  new  method  of  tuberculosis  case-find- 
ing has  already  been  put  into  operation  but 
it  is  too  early  yet  to  evaluate  its  success.  It 
is  believed,  however,  that  it  will  prove  to  be 
efficient.  To  permit  a further  frontal  attack 
on  tuberculosis,  it  is  hoped  that  sufficient 
funds  will  be  appropriated  to  permit  pro- 
phylactic treatment  with  isoniazide  of  per- 
sons who  have  been  direct  contacts  of  tuber- 
culosis patients. 

TETANUS  DEATHS  IN  U.  S. 

Deaths  from  tetanus  in  southern  states  ac- 
count for  63  per  cent  of  the  total  number  for 
the  nation — this,  in  spite  of  the  fact  that  the 
south  has  only  24  per  cent  of  the  country’s 
population. 

Writing  in  the  current  Southern  Medical 
Journal,  four  New  Orleans  physicians  reveal 
some  statistics  on  tetanus  mortality  that  will 
surprise  those  who  believe  that  death  from 
this  cause  was  a thing  of  the  past. 

A simple  example  from  records  of  New 
Orleans  Charity  Hospital  serves  to  show  that 
tetanus  is  still  a dangerous  threat  to  life.  In 
1957-58  there  were  three  times  as  many  cases 
of  polio  as  tetanus  at  this  hospital,  but  there 
were  seven  times  as  many  deaths  from 
tetanus. 

Comparing  regional  and  national  figures, 
the  doctors  cite  the  incidence  of  tetanus 
deaths  in  the  United  States  as  0.19  per  year 
per  100,000  population.  However,  the  un- 
equal geographical  distribution  is  apparent 
with  0.50  deaths  per  year  per  100,000  popula- 
tion for  eleven  of  the  southern  states,  leaving 
a figure  of  0.09  deaths  per  year  per  100,000 
population  for  the  other  37  states. 

Three  phases  of  tetanus  prevention  are 
discussed  by  the  doctors  which,  they  say,  are 
generally  recognized  and  subscribed  to  but 
apathetically  applied.  They  are  care  of  the 
wound,  active  immunization  of  the  general 


population  and  the  discarding  of  routine  ad- 
ministration of  antitoxin. 

Quoting  from  a book  on  the  subject  by  Dr. 
Ralph  Spaeth,  the  doctors  remind  that  “an 
ounce  of  good  surgical  care  of  wounds  is 
worth  a barrel  of  antitoxin.”  This  assumes 
particular  importance  in  the  care  of  the  pati- 
ent who  has  not  received  antitoxin. 

Even  though  the  authors  of  this  paper  do 
not  in  any  sense  belittle  the  value  of  anti- 
toxin, they  urge  selective  administration  and 
adequate  dosage  and  advise  against  its  un- 
necessary use.  If  a wound  can  be  thorough- 
ly cleansed,  it  would  appear  that  antitoxin  is 
not  necessary.  But  old,  dirty,  contused  or 
deep  puncture  wounds  which  cannot  be  ade- 
quately cleaned  and  de-tissued  call  for  anti- 
toxin dosage  in  the  proper  amounts. 

The  summing-up  provides  a thorough  guide 
to  care  and  treatment  of  wounds  and  deserves 
to  be  studied  by  physicians.  Briefly  it  is: 

1.  Thorough  cleansing  of  the  wound, 
cutting  away  of  diseased  tissue;  leaving  teta- 
nus-prone wounds  open,  particularly  when  it 
is  impossible  to  be  certain  that  all  foreign 
material  and  non-viable  tissue  is  removed. 

2.  If  a patient  has  been  previously  im- 
munized with  tetanus  toxoid,  administering 
of  0.5  cc.  booster  dose  for  new  wounds,  if  the 
booster  dose  or  basic  series  was  not  received 
within  the  preceding  twelve  months. 

3.  As  regards  serum,  tetanus  antitoxin,  it 
is  not  needed  in  truly  uncontaminated 
wounds.  Here  the  relative  danger  of  reaction 
to  tetanus  antitoxin  versus  the  danger  of 
tetanus  must  be  considered. 

4.  The  tetanus  virus  is  usually  sensitive 
to  antibiotics,  particularly  penicillin,  but  this 
fact  cannot  be  relied  upon  as  the  sole  pro- 
tective measure. 

Everj^  physician  must  decide,  the  doctors 
conclude,  what  anti-tetanus  measures  should 
be  used  in  each  case  because  of  the  high 
mortality  of  the  disease  and  sometime  mor- 
tality from  tetanus  autitoxin.  And  southern 
physicians  in  particular  must  be  constantly 
alert  to  aid  in  lowering  the  high  mortality 
tetanus  rate  in  their  own  area. 


JULY  I960— VOL.  30,  NO.  I 


51 


DEPARTMENT  OF  HEALTH 


BUREAU  OF  PREVENTABLE  DISEASES 

W.  H.  Y.  Smith,  M.  D.,  Director 


CURRENT  MORBIDITY  STATISTICS 
1960 


Typhoid  and  paratyphoid 

Undulant  fever  

Meningitis  - - - 

Scarlet  fever  _ - . 

Whooping  cough  

Diphtheria  

Tetanus  ..  - - 

Tuberculosis  - 

Tularemia  

Amebic  dysentery  . 

Malaria  - ..  - ...  — 

Influenza  

SmallpoTC  - - 

Measles  

Poliomyelitis  — 

Encephalitis  

Chickenpox  

Typhus  fever 

Mumps  — ■ 

Cancer  - — - — 

Pellagra  - 

Pneumonia  - 

Syphilis  — 

Chancroid  — — 

Gonorrhea  — 

Rabies — Human  cases 

Pos.  animal  heads 


•E.  E. 


April 

May 

May 

1 

3 

2 

3 

2 

1 

6 

3 

12 

151 

49 

41 

8 

6 

64 

6 

1 

3 

2 

1 

3 

164 

134 

216 

2 

0 

5 

. 10 

3 

1 

0 

0 

0 

. 935 

82 

214 

0 

0 

0 

..  426 

256 

1.717 

..  0 

0 

3 

3 

4 

2 

..  252 

69 

239 

1 

0 

0 

268 

80 

270 

814 

585 

507 

0 

0 

0 

345 

237 

202 

..  173 

163 

179 

4 

1 

8 

280 

321 

368 

0 

0 

0 

. 11 

9 

0 

As  reported  by  physicians  and  including  deaths  not  re- 
ported as  cases. 

• E.  E.— The  estimated  expectancy  represents  the  median 
incidence  of  the  past  nine  years. 


^ ^ 


BUREAU  OF  LABORATORIES 

Thomas  S.  Hosty.  Ph.D.,  Director 

SPECIMENS  EXAMINED 
May  1960 


Examinations  for  malaria  30 

Examinations  for  diphtheria  bacilli 

and  Vincent’s 31 

Agglutination  tests 586 

Typhoid  cultures  (blood,  feces  and  urine).  584 

Brucella  cultures  

Examinations  for  intestinal  parasites 3,131 

Darkfield  examinations - 

Serologic  tests  for  syphilis  (blood  and 

spinal  fluid) .28,902 

Examinations  for  gonococci . 1,861 

Complement  fixation  tests  . . 80 

Examinations  for  tubercle  bacilli  . 3,792 

Examinations  for  Negri  bodies  (smears 

and  animal  inoculation) 223 

Water  examinations — 2,534 

Milk  and  dairy  products  examinations — 4,484 

Miscellaneous  examinations  — 3,396 


Total-  .49,642* 

*This  includes  a total  of  3,162  specimens  exam- 
ined by  the  Mobile  Branch  Laboratory  during  April, 
such  report  not  being  received  in  time  to  include 
in  April  report. 


BUREAU  OF  VITAL  STATISTICS 

Ralph  W.  Roberts,  M.  S„  Director 

PROVISIONAL  BIRTH  AND  DEATH 
STATISTICS,  AND  COMPARATIVE  DATA, 
MARCH  1960 


Live  Births 
Deaths 

Causes  of  Death 

Number 
Registered 
During 
March  1960 

Rates* 

(Annual  Basis) 

1958 

Total 

1 

White 

Non- 

White 

i960 

1959 

Live  births. 

6,605 

4,181 

2,424 

23.9 

24.2 

25.3 

Deaths  . 

2,930 

1,766 

1,164 

10.6 

9.0 

10.4 

Fetal  deaths  

136 

52 

84 

20.2 

20.6 

20.2 

Infant  deaths — 

under  one  month .. 

127 

71 

56 

19.2 

21.1 

27.1 

under  one  year 

211 

103 

108 

31.9 

31.6 

42.8 

Maternal  deaths 

3 

3 

4.4 

8 3 

8 6 

Causes  of  Death 

Tuberculosis,  001-019. 

24 

11 

13 

8.7 

11.3 

12.9 

Syphilis,  020-029 

3 

1 

2 

1.0 

1.8 

1.8 

Dysentery,  045-048 

Diphtheria.  055 

1 

1 

0.4 

0.4 

Whooping  cough,  056 

1.1 

Meningococcal  infec- 

tions,  057 

2 

1 

1 

0 7 

1 8 

Poliomyelitis,  080,  081 

0.7 

Measles,  085 

4 

2 

2 

1.4 

0.4 

0.4 

Malignant 

neoplasms.  140-205.. 

SOI 

210 

91 

109.1 

113.5 

117.3 

Diabetes  mellitus,  260 

50 

30 

20 

18.1 

11.7 

17.7 

Pellagra,  281 

0.4 

0.4 

Vascular  lesions  of 

central  nervous 

system,  330-334 

447 

240 

207 

162.0 

121.6 

150.5 

Rheumatic  fever. 

400-402  

3 

3 

1.1 

0.4 

Diseases  of  the 

heart,  410-443 

975 

649 

326 

353.3 

310.7 

323.8 

Hypertension  with 

heart  disease,  440-443 

189 

78 

111 

68.5 

58.0 

60.9 

Diseases  of  the 

arteries,  450-456 . ....  . 

72 

48 

24 

26.1 

19.0 

28.4 

Influenza,  480-483 

104 

61 

43 

37.7 

5.5 

25.4 

Pneumonia,  all  forms. 

490-493  

127 

70 

57 

46.0 

28.5 

46.5 

Bronchitis,  500-502 

11 

7 

4 

4.0 

1.5 

3.0 

Appendicitis,  550-553 

4 

2 

2 

1.4 

0.4 

0.4 

Intestinal  obstruction 

and  hernia,  560, 

561,  570  _.... 

10 

5 

5 

3.6 

3.3 

4.8 

Gastro-enteritis  and 

colitis,  under  2, 

571.0,  764 

11 

8 

3 

4.0 

1.5 

2.6 

Cirrhosis  of  liver,  581 

13 

9 

4 

4.7 

5.8 

7.7 

Diseases  of  pregnancy 

and  childbirth,  640-689 

3 



3 

4.4 

8.3 

8.6 

Congenital  malforma- 

tions,  750-759  

28 

19 

9 

4.2 

6.9 

4.8 

Immaturity  at  birth. 

774-776  .. 

44 

22 

22 

6.7 

6.6 

8.3 

Accidents,  total,  800-962 

162 

94 

68 

58.7 

58.4 

64.5 

Motor  vehicle  acci- 

dents.  810-835,  960 

61 

40 

21 

22.1 

23.0 

24.7 

All  other  defined 

causes  

391 

229 

162 

141.7 

143.5 

158.6 

Ill-defined  and  un- 

known  causes. 

780-793,  795  ....  

140 

48 

92 

50.7 

29.2 

39.8 

‘Rates:  Birth  and  death — per  1,000  population 
Infant  deaths — per  1,000  live  births 
Fetal  deaths — per  1,000  deliveries 
Maternal  deaths — per  10,000  deliveries 
Deaths  from  specified  eauses — per  100.000  population 


52 


J.  M.  A.  ALABAMA 


THE  JOURNAL 

of 

THE  MEDICAL  ASSOCIATION  OF  THE  STATE  OF  ALABAMA 

Published  Under  the  Auspices  of  the  Board  of  Censors 
Vol.  30  August  1960  No.  2 


Clinical  Problems  In 

The  Management  Of  Hemophilia 

H.  BROOKS  GOTTEN.  M.  D. 

Fairfield.  Alabama 


In  recent  years  it  has  become  apparent  that 
the  clinical  picture  formerly  diagnosed  as 
lue  to  hemophilia  may  be  caused  by  several 
nherited  bleeding  disorders.  Patients  with 
such  findings  are  deficient  in  one  of  the  co- 
agulation proteins  which  react  with  platelet 
'actors  to  activate  thromboplastin,  the  first 
ahase  of  the  coagulation  process.  The  term 
aemophilia  is  reserved  for  the  most  frequent 
and  clinically  most  severe  disorder.  The  de- 
ucient  protein  has  been  called  antihemophilic 
'actor,  or  globulin  (AHF  or  AHG)  b or 
thromboplastinogen-.  The  generic  term 
‘hemophilioid  states”  has  been  proposed  to 
nclude  the  less  severe  plasma  thromboplas^ 
;in  component  deficiency  (Christmas  disease, 
PTC  deficiency) , and  several  other  quite  rare 
deficiencies  of  coagulation  proteins'*.  This 
discussion  is  limited  to  classic  hemophilia 
which  is  clinically  characterized  by  severe 


Dr.  Gotten  is  a graduate  of  the  University  of 
Pennsylvania  School  of  Medicine  and  is  a member 
of  the  department  of  internal  medicine  at  Lloyd 
Noland  Hospital  in  Fairfield,  Alabama. 


hemorrhagic  episodes,  especially  involving 
the  joints.  The  disease  is  transmitted  by  the 
female,  affecting  only  males.  Coagulation  as 
measured  by  the  clotting  time  is  prolonged. 
During  coagulation  there  is  poor  utilization 
of  prothrombin  as  shown  by  the  prothrombin 
consumption  test. 

Despite  better  understanding  and  labora- 
tory recognition  of  hemophilia,  the  disease 
is  so  infrequently  encountered  that  most 
physicians  lack  sufficient  experience  neces- 
sary to  feel  confident  in  its  treatment.  The 
purpose  of  this  discussion  is  to  present  a se- 
ries of  cases  illustrating  certain  practical 
considerations  in  management  which  seem 
worthy  of  emphasis. 

Diagnostic  Difficulty  as  Result  of 
U nsatisfactory  Veni puncture 

This  15  month  old  white  male,  seen  in  1954 
through  the  courtesy  of  Doctor  Clifford  La- 
mar, first  exhibited  evidence  of  a bleeding 
disorder  at  six  months  of  age.  There  was  no 


MANAGEMENT  OF  HEMOPHILIA 


family  history  of  abnormal  bleeding.  Hem- 
orrhagic phenomena  included  bruising  be- 
neath diaper  pins,  large  unexplained  bruises 
of  the  lower  extermities,  and  repeated  large 
hemorrhages  in  the  frontal  region.  These 
hematomas  of  the  forehead  were  described 
as  egg-sized  and  probably  resulted  from 
minor  trauma.  On  one  occasion  the  lids  be- 
came so  swollen  the  eyes  could  not  be  opened. 
Coagulation  studies  were  performed  by  an 
excellent  clinical  laboratory  after  two  severe 
forehead  hemorrhages.  The  platelet  count, 
prothrombin  time,  and  venous  clotting  time 
were  normal  on  both  occasions.  Clot  retrac- 
tion was  normal.  The  bleeding  time  was  re- 
ported as  “longer  than  25  minutes”.  (The 
pricked  ear  actually  continued  to  bleed  for 
the  next  three  days!).  The  vascular  type  of 
pseudohemophilia  was  considered,  but  only 
questionable  benefit  resulted  from  treatment 
with  ACTH. 

The  patient  was  referred  for  further  study 
after  developing  his  fifth  hematoma  of  the 
forehead.  This  measured  five  cm.  in  greatest 
dimension.  There  were  scattered  ecchymoses 
over  the  lower  extremities  and  in  the  right 
groin.  The  venous  clotting  time  in  standard 
glass  tubes  measured  18  minutes.  The  normal 
for  this  modified  Lee-White  method,  using 
two  tubes,  is  4-12  minutes.  Deficiency  of  a 
coagulation  plasma  factor  was  demonstrated 
by  restoration  of  a normal  coagulation  time 
when  the  patient’s  blood  was  mixed  with 
normal  blood. 

The  child  was  studied  again  at  a later  date. 
A pediatric  resident,  an  expert  in  the  art  of 
performing  clean,  quick  venipuncture  in  in- 
fants, obtained  venous  blood  which  had  not 
clotted  after  38  minutes.  Mixture  of  the 
patient’s  blood  with  blood  from  another  pati- 
ent previously  found  to  have  classical  hemo- 
philia (Case  6)  showed  markedly  prolonged 
coagulation  of  the  mixture.  (Fig.  1.)  This 
indicated  that  both  patients  lacked  the  same 
coagulation  factor,  and  had  the  same  coagu- 
lation disorder.  In  spite  of  plasma  adminis- 
tration for  abnormal  bleeding  after  the  cor- 
rect diagnosis  was  established,  the  patient 
expired  later  as  the  result  of  hemorrhage. 


Patient’s  blood,  cc 

2.0 

1.6 

1.2 

0.8 

0.4 

0 

Normal  blood,  cc 

0 

0.4 

0.8 

1.2 

1.6 

2.0 

Clotting  time,  minutes 

18' 

6V2 

^V■z 

51/i 

5>/i 

5' 

Correction  of  Defective  Coagulation  in  Case  1 
by  Normal  Blood 

Patient’s  blood,  cc  2.0  1.6  0.4  0 

AHG-deficient  bid,  cc  0 0.4  1.6  2.0 

Clotting  time, 

minutes  38  | ' 30'  21'  21' 

FIG.  1 

Inability  of  Hemophilic  Blood  to  Correct  Defective 
Coagulation  in  Case  1 

Comment — This  patient  illustrates  that  al- 
most all  errors  in  the  technique  of  obtaining 
blood  for  diagnostic  study  tend  to  “normal- 
ize” any  test  used  in  the  diagnosis  of  hemo- 
philia or  related  disorders.  All  diagnostic 
procedures  must  be  performed  on  “pure” 
venous  blood,  uncontaminated  by  even  mi- 
nute quantities  of  tissue  juice  (which  is  very 
high  in  thromboplastic  activity) ■*.  If  the 
vein  is  not  entered  on  the  first  attempt,  the 
needle  and  syringe  should  be  replaced,  and 
the  specimen  obtained  at  a different  site.  We 
prefer  to  use  two  syringes,  discarding  the 
first  when  the  vein  has  been  entered  and  ap- 
proximately 1 cc.  of  blood  has  been  with- 
drawn. With  satisfactory  specimens  of  ven- 
ous blood,  the  prolongation  of  the  clotting 
time  is  relatively  constant  in  a given  patient, 
though  clinical  hemorrhagic  episodes  occur 
in  a poorly  understood  “cyclic”  fashion-’. 
In  the  present  instance  the  variable  clotting  , 
times  attest  to  the  considerable  difficulty  en- 
countered in  making  the  venipunctures.  ! 

From  a statistical  standpoint  alone,  when- 
ever markedly  abnormal  bleeding  in  a male  ■ 
infant  or  small  child  is  encountered,  hemo- 
philia is  much  more  likely  than  any  other' 
bleeding  dyscrasia".  As  was  true  of  the ' 
pediatrician  in  the  present  case,  the  alert’ 
physician  will  refuse  to  accept  even  repeat-- 
ed  laboratory  reports  of  a normal  clotting 
time,  prothrombin  consumption  test',  partial, 
thromboplastin  time^,  or  any  other  diagnostic 
procedure  until  absolutely  certain  that  a 
quick  clean  venipuncture  was  performed  in 
obtaining  the  blood  specimen.  A carefully 
elicited  past  medical  history  pertaining  to  ab- 
normal bleeding  is  much  more  valuable  than 


54 


J.  M.  A.  ALABAMA 


MANAGEMENT  OF  HEMOPHILIA 


hurried,  routine  clotting  and  bleeding  times 
in  the  pre-operative  evaluation  of  a patient 
scheduled  for  tonsillectomy  or  dental  ex- 
traction'*. 

This  case  also  demonstrates  the  need  for 
care  in  performing  a bleeding  time  determi- 
nation in  a patient  suspected  of  hemophilia. 
Retraction  of  the  small  vessels  following  the 
skin  puncture,  leads  to  a “normal”  bleeding 
time  determination.  However,  when  the  in- 
jured vessels  relax  somewhat  later,  recurrent 
bleeding  ensues,  and  may  persist  for  days*. 
Cessation  of  bleeding  occurs  if  gentle  pres- 
sure is  applied  to  the  bleeding  point  for  suf- 
ficiently prolonged  periods. 

Differcnficitiou  Befivccu  Heniavfbrosis 
and  Pyogenic  Synovitis 

This  white  male  infant  was  first  seen 
through  the  courtesy  of  Doctors  Alfred  Da- 
vis and  George  McCullough  in  1957.  The 
child  was  found  to  have  hemophilia  at  five 
months  of  age  when  studied  elsewhere  be- 
cause of  undue  bruising.  A first  cousin  on 
his  mother’s  side  had  died  as  the  result  o 
hemorrhage  due  to  hemophilia  (Case  6) . The 
child  experienced  swelling  of  both  elbows 
and  of  the  right  knee  on  several  occasions. 
The  joint  swelling  had  subsided  each  time 
after  3-4  days  without  need  for  medical  at- 
tention. He  was  first  admitted  to  the  Lloyd 
Noland  Hospital  at  15  months  of  age  because 
of  progressive  swelling  of  the  left  knee  of 
three  weeks  duration.  The  parents  denied 
any  significant  symptoms  otherwise.  Exami- 
nation showed  a temperature  of  103°  and 
marked  swelling  of  the  left  knee  which  was 
hot  and  exquisitely  tender.  The  hemogram 
showed  an  RBC  of  2,800,000,  a hemoglobin  of 
7.9  gms.%,  and  a WBC  of  62,700  with  56% 
segmented  neutrophils,  25%  stabs,  14%  lym- 
phocytes and  5%  monocytes.  Platelets  num- 
bered 625,000  per  cu.  ml.  Appropriate  coagu- 
lation studies  confirmed  the  diagnosis  of 
hemophilia  (AHG  deficiency) . 

The  child  was  given  250  cc.  of  fresh  blood, 
followed  by  50  cc.  of  fresh  frozen  plasma 


every  eight  hours  (approximately  five  cc. 
per  kilogram  of  body  weight).  The  tempera- 
ture fluctuated  between  100°  and  104°. 
Though  the  WBC  decreased  to  40,650  on  the 
second  hospital  day,  no  clinical  improvement 
was  noted.  We  felt  that  all  of  the  findings 
could  be  explained  on  the  basis  of  severe 
hemorrhage  into  the  joint.  However,  Doc- 
tor Chestley  Yelton,  the  orthopedic  consult- 
ant, suspected  a septic  infection  of  the  joint, 
and  proved  this  by  aspiration  of  67  cc.  of 
gross  pus.  Diplococcus  pneumoniae  was  sub- 
sequently cultured  from  this  material.  Plas- 
ma was  administered  thereafter  only  before 
two  further  aspirations  of  the  joint.  The 
child  was  treated  with  oral  penicillin  and  in- 
stillation of  penicillin  into  the  joint  after 
each  aspiration.  Recovery  was  rapid  and  un- 
eventful. 

Comment. — Hospital  charts  for  86  admis- 
sions by  14  hemophilic  patients  were  care- 
fully reviewed.  Hemarthrosis  is  usually 
associated  with  only  a low  grade  fever,  the 
temperature  seldom  exceeding  101°.  Infre- 
quently patients  were  admitted  with  a tem- 
perature of  102°-103°,  but  the  temperature 
usually  fell  below  100°  soon  after  adminis- 
tration of  plasma.  A spiking  fever  for  sev- 
eral days  was  noted  only  on  two  admissions 
for  hemarthrosis.  Bleeding  into  joints  was 
accompanied  by  a normal  or  only  slightly 
elevated  leukocyte  count.  Leukocytes  usual- 
ly range  from  10,000  to  15,000  in  the  acute 
stages.  Excepting  the  present  case,  the  high- 
est count  noted  was  20,900. 

Some  writers  have  advocated  joint  aspira- 
tion as  routine  treatment  for  all  severe  acute 
hemophilic  hemarthroses*'*.  Such  advo- 
cates feel  that  disability  is  thereby  lessened. 
We  do  not  subscribe  to  this  viewpoint,  having 
often  been  impressed  by  the  relatively  slight 
disability  resulting  from  innumerable  joint 
hemorrhages  over  periods  of  many  years.  A 
blood-laden  joint  serves  as  an  excellent  cul- 
ture medium  for  any  bacteria  which  might  in- 
advertently be  introduced  during  aspiration. 
Prompt  diagnostic  aspiration,  however, 
should  be  performed  when  joint  sepsis  rather 


AUGUST  I960— VOL.  30.  NO.  2 


55 


MANAGEMENT  OF  HEMOPHILIA 


than  hemorrhage  is  suggested  by  spiking 
fever  and  hyperleukocytosis. 

Ecirly  Treat  molt  witl.i  Plasma 
after  Head  Injury 

This  37  year  old  white  male  with  a classi- 
cal family  history  of  hemophilia  has  exhib- 
ited abnormal  bleeding  since  infancy.  He 
has  experienced  numerous  hemorrhages  in- 
to muscles  and  joints,  and  has  been  hospital- 
ized many  times  for  plasma  infusions.  The 
clotting  time  of  his  venous  blood  is  usually 
about  2 hours,  and  prothrombin  utilization 
during  coagulation  is  greatly  decreased.  Ap- 
propriate coagulation  studies  have  shown 
that  his  blood  does  not  correct  the  clotting 
defect  of  hemophilic  blood. 

In  1952,  he  required  hospitalization  for  a 
period  of  four  weeks  following  a minor  auto- 
mobile accident  in  which  the  left  side  of  the 
face  was  contused.  He  was  given  250  cc.  of 
plasma  initially,  then  100  cc.  every  four  hours 
for  two  days.  He  received  50  cc.  of  plasma 
at  intervals  varying  from  4-12  hours  there- 
after, with  maintenance  of  the  clotting  time 
within  normal  limits.  Further  suborbital  and 
periorbital  bleeding  involving  the  left  eye 
occurred  on  two  occasions  despite  the  normal 
clotting  time. 

We  first  saw  the  patient  in  1957  through 
the  courtesy  of  Doctor  Bruce  K.  Johnson 
approximately  three  hours  after  another  au- 
tomobile accident.  He  had  been  struck  on 
the  left  side  of  the  head  and  on  the  right 
shoulder,  and  apparently  had  experienced 
transient  loss  of  consciousness.  On  examina- 
tion he  was  alert,  moved  all  extremities,  and 
complained  only  of  left  fronto-temporal 
headache  and  pain  in  the  left  eye.  There 
was  a tender  lump  on  the  right  side  of  the 
forehead  measuring  six  cm.  in  greatest  di- 
mension. There  was  a diffuse  tender  swelling 
of  mild  degree  in  the  left  temporal  region 
extending  downward  to  the  malar  eminence. 
The  knees  and  elbows  showed  mild  deformi- 
ty and  limitation  of  motion  as  the  result  of 
repeated  hemarthroses  in  the  past. 


The  left  pupil  appeared  slightly  larger  than 
the  right,  the  right  lid  drooped  slightly,  and 
the  head  was  tilted  slightly  to  the  right.  Both 
pupils  responded  well  to  light,  and  the  fundi 
were  normal.  The  patient  did  not  think  that 
the  very  slight  ptosis  and  anisocoria  had  been 
present  before  the  accident. 

He  was  given  500  cc.  of  fresh  frozen  plasma 
immediately,  and  again  after  eight  hours.  He 
then  received  250  cc.  of  plasma  at  eight  hour  ^ 
intervals  for  two  doses,  finally  being  reduced  i 
to  250  cc.  every  12  hours  for  the  next  four 
days.  The  morning  after  the  accident  there 
was  bluish  discoloration  around  the  left  eye. 
The  patient  complained  of  diplopia  when 
tilting  the  head  to  the  left,  considerable  head- 
ache, and  experienced  some  impairment  of 
opening  the  mouth.  These  symptoms  were 
presumed  to  be  due  to  dissection  of  blood 
into  the  retrobulbar  and  temperomandibular 
regions.  The  patient  was  seen  by  Doctor  N. 

E.  Miles  for  ophthalmologic  evaluation,  and 
some  overaction  of  the  left  inferior  oblique 
muscle  was  noted.  Careful  funduscopic 
examination  and  visual  field  determinations 
failed  to  suggest  any  intracranial  pathology. 

It  was  felt  that  the  muscle  overactivity  had 
probably  been  present  from  birth,  though 
never  previously  noted.  On  ophthalmologic 
re-evaluation,  however,  six  months  later  the 
patient’s  symptoms  and  findings  had  com- 
pletely subsided,  indicating  that  these  had 
been  the  result  of  the  accident  rather  than 
congenital. 

The  patient  is  intelligent,  has  an  excellent 
understanding  of  his  disease,  and  largely  de- 
termines the  type  of  therapy  used  for  his 
recurring  hemarthroses.  During  the  past 
two  years  he  has  stored  his  own  supply  of 
fresh  frozen  plasma  in  a deep  freeze  at  home. 
(This  is  prepared  for  him  by  the  Hemophilia 
Plasma  Bank  at  the  University  Hospital  un- 
der the  direction  of  Doctor  S.  D.  Palmer.) 
Most  exacerbations  of  joint  pain  are  managed 
conservatively  at  home.  Whenever  he  ex- 
periences severe  pain  and  swelling  in  one  of 
his  joints,  he  is  given  an  infusion  of  300-400 
cc.  of  plasma,  and  is  then  allowed  to  return 
home.  This  has  proven  extremely  satisfac- 


56 


J.  M.  A.  ALABAMA 


MANAGEMENT  OF  HEMOPHILIA 


tory  in  decreasing  his  period  of  hospitaliza- 
tion and  disability.  In  every  instance  this 
has  stopped  the  bleeding  with  rapid  subsid- 
ence of  his  discomfort.  It  has  allowed  him  to 
lead  a much  more  normal  life  with  only  one' 
hospitalization  during  this  time.  This  oc- 
curred when  he  developed  a large  abscess 
of  the  buttocks.  Unfortunately  the  patient 
has  become  addicted  to  narcotics.  The  ab- 
scess apparently  resulted  from  narcotic  in- 
jections. His  narcotic  requirement  has  been 
gradually  decreased  over  a period  of  years 
(without  his  knowledge)  by  Doctor  Johnson. 
The  patient  has  continued  to  operate  a small 
business,  and  to  lead  a very  satisfying  and 
useful  life. 

Comment. — This  patient  illustrates  well 
the  advisability  of  immediate  administration 
of  fresh  plasma  or  blood  whenever  there  has 
been  any  significant  cranial  trauma  in  a pa- 
tient with  hemophilia.  Neurological  exami- 
nation on  admission  was  negative,  and  skull 
films  revealed  no  fractures.  This  patient  sub- 
sequently showed  definite  objective  findings 
as  well  as  subjective  complaints  compatible 
with  slight  intracranial  or  orbital  hemor- 
rhage. It  seems  certain  that  had  plasma  ad- 
ministration been  withheld,  serious  disabili- 
ty might  have  resulted. 

Sufficient  plasma  must  be  given  to  achieve 
and  maintain  a hemostatic  level  of  anti- 
hemophilic globulin  in  the  blood  in  order 
that  hemostasis  and  healing  can  occur.  In 
1952,  this  patient  was  given  frequent  in- 
fusions of  plasma,  sufficient  to  correct  his 
clotting  times,  but  inadequate  to  stop  his 
bleeding.  Only  two  per  cent  of  the  normal 
amount  of  circulating  antihemophilic  factor 
is  required  to  correct  the  clotting  time,  and 
only  five  per  cent  is  needed  to  make  the  pro- 
thrombin consumption  test  normal.  Maxi- 
mum hemostatic  effect  occurs  only  when  suf- 
ficient plasma  has  been  given  to  achieve  an 
AHG  blood  level  30%  of  normal”.  Fortu- 
nately, most  hemophilics  respond  to  less  than 
the  tremendous  quantity  of  plasma  necessary 
to  furnish  this  level.  In  our  experience  good 
results  have  been  obtained  with  the  admin- 


istration of  approximately  five  cc.  of  plasma 
per  kilogram  of  body  weight  every  8-12  hours. 

Den  fell  Cave  in  Hemophilia 

This  19  year  old  white  male  has  shown  a 
severe  bleeding  tendency  since  early  infancy. 
There  is  no  family  history  of  a bleeding 
dyscrasia,  but  appropriate  study  has  shown 
him  to  be  markedly  deficient  in  antihemo- 
philic globulin.  There  have  been  numerous 
hospital  admissions  for  recurring  hemar- 
throses.  He  had  been  advised  repeatedly  that 
multiple  tooth  extractions  were  necessary. 
In  spite  of  the  fact  that  his  pillow  had  been 
blood  stained  each  morning  for  over  a year 
as  the  result  of  gingival  oozing,  the  patient 
and  his  family  had  never  attempted  to  obtain 
sufficient  plasma  to  allow  the  necessary  den- 
tal work.  Definitive  treatment  was  finally 
precipitated  by  the  development  of  severe 
pain  and  swelling  in  the  right  lower  jaw  one 
week  prior  to  his  thirty-fifth  admission  to 
the  Lloyd  Noland  Hospital.  Examination 
showed  seven  teeth  which  were  beyond  re- 
pair. He  was  placed  on  antibiotics,  and  ar- 
rangements were  made  for  a sufficient  num- 
ber of  blood  donors  to  report  to  the  Hemo- 
philia Plasma  Bank  at  the  University  Hospi- 
tal, where  units  containing  250  cc.  of  fresh 
frozen  plasma  were  prepared.  On  the  day  of 
operation,  the  patient  was  given  250  cc.  of 
fresh  frozen  plasma  at  6: 00  A.M.,  and  a second 
unit  was  administered  during  surgery  three 
hours  later.  Endotracheal  anesthesia  with 
cyclopropane  was  administered  by  Doctor  R. 
W.  Grady,  great  care  being  taken  to  avoid 
trauma  to  the  airway.  Seven  severely  cari- 
ous teeth  were  removed  by  Doctor  Charles 
Goodwin  with  no  more  bleeding  than  normal- 
ly occurs.  Temporary  plastic  prostheses  cov- 
ering the  extraction  sites  in  each  quadrant  of 
the  jaw  had  been  prepared  preoperatively 
and  were  applied  immediately  following  the 
operation.  Postoperatively  the  patient  was 
given  a unit  of  plasma  every  eight  hours. 
Ice  bags  were  applied  to  the  jaws  and  an  ice 
collar  was  maintained  for  several  hours.  A 
tracheotomy  set  was  kept  nearby,  but  the 


AUGUST  I960— VOL.  30,  NO.  2 


57 


MANAGEMENT  OF  HEMOPHILIA 


patient  never  showed  evidence  of  bleeding 
into  the  soft  tissues.  The  plasma  was  reduced 
to  one  unit  every  12  hours  on  the  third  post- 
operative day  and  was  discontinued  the 
fourth  day.  Recurrent  bleeding  of  mild  de- 
gree occurred  which  could  not  be  stopped 
with  topical  thrombin,  and  was  controlled 
only  temporarily  by  plasma  every  12  hours 
for  an  additional  two  days.  Bleeding  finally 
stopped  after  resumption  of  plasma  admin- 
istration every  eight  hours  for  five  consecu- 
tive days. 

The  patient  was  given  35  units  of  plasma 
during  a period  of  14  days.  With  the  last  few 
infusions  one  gained  the  clinical  impression 
that  slight  bleeding  occurred  immediately 
after,  and  therefore  possibly  resulted  from 
the  administration  of  plasma.  The  venous 
clotting  time,  however,  and  prothrombin 
consumption  were  within  normal  limits.  A 
state  of  hypervolemia  resulting  from  infusion 
of  such  large  amounts  of  plasma  protein  was 
considered,  but  a blood  volume  determina- 
tion was  not  performed.  The  serum  proteins 
measured  8 gm.%,  67.5%  of  which  was  al- 
bumin. The  electrophoretic  pattern  ap- 
peared to  be  perfectly  normal.  The  patient’s 
hemoglobin  fell  from  a level  of  14.9  gms.  to 
8.2  gms.  but  had  returned  to  normal  after  six 
weeks  of  oral  iron  therapy. 

Comment. — Generally  it  would  seem  inad- 
visable to  extract  more  than  two  teeth  at 
any  one  time.  These  should  be  confined  to 
a single  quadrant  of  the  jaw'-.  We  felt 
that  the  additional  risk  involved  in  removing 
all  seven  severely  carious  teeth  at  one  time 
was  justified  in  this  case  because  of  the  diffi- 
culty in  obtaining  sufficient  plasma.  Before 
dental  surgery  is  attempted,  it  should  be 
clearly  ascertained  by  appropriate  laboratory 
study  after  plasma  infusion  that  the  patient’s 
impaired  coagulation  is  correctible  by  plasma 
administration.  Enough  plasma  should  be 
immediately  available  to  administer  approxi- 
mately five  cc.  per  kilogram  of  body  weight 
in  children,  or  a minimum  of  200  cc.  every 
8-12  hours  in  adults  over  a period  of  7-10  days. 
In  retrospect  we  feel  that  plasma  was  dis- 
continued in  this  patient  several  days  too 


soon.  It  seems  likely  that  plasma  adminis- 
tration every  eight  hours  for  five  days  and  ev- 
ery 12  hours  for  two  additional  days  would 
have  allowed  satisfactory  organization  of  the 
clots  and  use  of  fewer  total  units.  This  is 
pure  speculation,  however,  since  there  are 
case  reports  in  the  literature  in  which  more 
than  one  hundred  infusions  of  plasma  were 
necessary'''. 

Hospitalization  for  dental  reasons  in  hemo- 
philia is  almost  as  common  as  hospitalization 
for  recurring  hemarthrosis.  There  should 
be  a very  real  and  close  liaison  between  den- 
tist and  physician  in  the  management  of  these 
patients.  Hospitalization  and  fresh  plasma 
and  blood  infusion  may  be  required  following 
such  simple  procedures  as  cleaning  of  the 
teeth.  Yet  these  patients  should  have  the  best 
possible  prophylactic  dentistry  in  order  to 
avoid  extractions  as  much  as  possible.  Dental 
procedures  performed  under  suboptimal  con- 
ditions can  be  associated  with  bleeding  into 
retro-pharyngeal  areas  leading  rapidly  to 
asphyxiation". 

Surgical  Procedures  in  Hemophilia 

This  11  year  old  white  male  first  exhibited 
unusual  bleeding  at  the  age  of  15  months 
wtoen  two  transfusions  proved  necessary  to 
stop  bleeding  from  a small  laceration  of  the 
upper  lip  injured  in  falling.  The  child  re- 
quired frequent  hospitalization  thereafter  for 
control  of  post-traumatic  bleeding  in  the 
form  of  hemarthroses,  hemorrhages  into  the 
muscles,  and  epistaxis  complicating  respira- 
tory infections.  On  one  occasion,  after  sus- 
taining a laceration  of  the  scalp,  10  trans- 
fusions were  required  before  healing  oc- 
curred. A diagnosis  of  hemophilia  had  been 
made,  though  there  was  no  family  history  of 
abnormal  bleeding.  He  had  been  given  oral 
vitamin  K for  a prolonged  period  with  no 
benefit.  He  was  transferred  from  another 
city  to  Birmingham  in  February,  1955,  one 
week  after  attempted  surgical  drainage  of  a 
recurrent  hemorrhage  into  the  right  knee 
joint.  Operation  had  been  followed  by  per- 


58 


J.  M.  A.  ALABAMA 


MANAGEMENT  OF  HEMOPHILIA 


sistent  bleeding  in  spite  of  administration  of 
blood  and  plasma  in  unknown  amounts. 

The  child  was  thin  and  appeared  chronical- 
ly ill.  He  weighed  68  pounds  and  had  a tem- 
perature of  101.8°.  He  showed  a Volkman’s 
contracture  of  the  left  hand,  the  result  of  a 
hemorrhagic  episode  six  years  previously. 
The  right  knee  had  a foul  odor,  and  showed  a 
bloody  drainage  from  vertical  incisions  on 
either  side  of  the  joint.  Laboratory  study  re- 
vealed a hemoglobin  of  8.5  gms.  (55%),  a 
WBC  of  10,650  with  a normal  differential,  and 
prolongation  of  the  clotting  time  of  venous 
blood.  Anemia  was  corrected  with  two  trans- 
fusions of  250  cc.  of  fresh  whole  blood.  The 
clotting  time  was  kept  within  normal  limits 
by  100  cc.  of  plasma  every  eight  hours  for  the 
first  five  days  and  every  12  hours  for  the  next 
two  weeks.  He  received  penicillin  and  chlor- 
tetracycline  for  three  days,  but  no  antibiotics 
thereafter  because  of  the  development  of 
urticaria.  There  was  only  mild  blood  stain- 
ing of  the  dressings,  which  was  felt  to  be 
consistent  with  liquefaction  of  clotted  blood. 

Under  the  direction  of  Doctor  Fletcher 
Comer,  Buck’s  traction  was  applied  one  week 
after  admission.  Three  weeks  after  admis- 
sion the  patient  was  allowed  up  in  a wheel 
chair  using  a posterior  splint,  the  medial  knee 
incision  having  healed  and  the  lateral  inci- 
sion showing  healthy  granulation  tissue.  Ac- 
tive motion  without  weight  bearing  was  start- 
ed six  weeks  after  admission.  He  was  allowed 
to  walk  with  a long  leg  brace  at  two  months 
when  both  wounds  were  healed.  On  dis- 
charge 31/2  rnonths  after  operation,  he  was 
able  to  walk  without  mechanical  aid  and 
showed  a gratifying  degree  of  motion  in  the 
recently  operated  knee. 

Comment. — This  child  required  40  infu- 
sions of  plasma,  two  transfusions  of  whole 
blood,  and  hospitalization  for  slightly  more 
than  three  months  because  of  an  ill-advised 
operative  procedure  which  accomplished 
nothing. 

Major  surgical  procedures  in  hemophiliacs 
are  associated  with  a mortality  rate  of  35% 
or  higheri'^.  All  elective  operative  proced- 


ures are  necessarily  contraindicated.  When 
emergency  surgery  is  mandatory,  the  patient 
should  be  prepared  with  fresh  blood  and  plas- 
ma immediately  beforehand,  and  adequate 
amounts  of  plasma  should  be  given  for  a 
minimum  of  7-10  days  postoperatively. 

Hemorrhage  into  the  bowel  wall  or  mesen- 
tery may  mimic  very  closely  such  acute  sur- 
gical conditions  as  a penetrating  or  perforated 
ulcer  and  small  or  large  bowel  obstruction. 
Hemorrhage  into  the  iliopsoas  muscles  is  not 
infrequent.  When  on  the  right,  it  may  close- 
Iv  simulate  acute  appendicitis.  Surgical  risk 
in  the  hemophiliac  may  well  exceed  the  risk 
of  acute  appendicitis  treated  with  conserva- 
tive medical  measures.  It  is  well  to  remem- 
ber that  intra-abdominal  or  retro-peritoneal 
bleeding  is  far  more  common  in  hemophiliacs 
than  are  the  usual  abdominal  emergencies^^. 

Development  of 
Circulating  A n ticoag nlant 

This  was  a 16  year  old  white  male  who  had 
exhibited  severe  bleeding  since  nine  months 
of  age.  A diagnosis  of  hemophilia  was  made 
though  there  was  no  known  family  history  of 
abnormal  bleeding  (Case  2,  a cousin  on  the 
mother’s  side,  was  born  after  this  patient’s 
death).  Throughout  life  the  patient  had  re- 
ceived an  estimated  200-300  transfusions  of 
fresh  plasma.  He  had  been  given  plasma 
prophylactically  once  a week  during  1952,  ap- 
parently with  only  slight  improvement  in  the 
frequency  of  hemorrhage  into  joints  and  mus- 
cles. 

Study  at  the  National  Institutes  of  Health 
in  January,  1955,  using  the  thromboplastin 
generation  test,  showed  that  the  patient’s 
plasma  lacked  antihemophilic  globulin.  Find- 
ings with  the  thromboplastin  generation  test 
as  well  as  recalcification  times  using  mix- 
tures of  the  patient’s  plasma  with  normal 
plasma  suggested  the  presence  of  a circulat- 
ing anticoagulant.  This  was  not  felt  to  be 
significant  clinically,  however,  since  the  ven- 
ous clotting  time  was  corrected  by  infusion 
of  as  little  as  80  cc.  of  fresh  frozen  plasma. 


AUGUST  I960— VOL.  30,  NO.  2 


59 


MANAGEMENT  OF  HEMOPHILIA 


Hospitalization  with  recurrent  hemarthro- 
sis  of  the  left  knee  was  necessary  approxi- 
mately three  months  later.  He  was  given 
150  cc.  of  plasma  initially,  then  100  cc.  every 
eight  hours.  On  admission,  the  venous 
clotting  time  was  74  minutes,  and  the  follow- 
ing morning  it  had  decreased  to  only  46  min- 
utes. Despite  continued  administration  of 
100  cc.  every  eight  hours,  the  clotting  times 
on  the  third  and  fourth  hospital  days  were 
32  minutes  and  33  minutes  respectively.  The 
infusions  were  increased  to  150  cc.  every  eight 
hours,  and  plasma  prepared  at  a second  blood 
bank  was  tried  with  no  appreciable  improve- 
ment. On  April  3,  1955,  a clotting  time 
drawn  while  the  patient  was  being  given  500 
cc.  of  very  fresh  blood  in  the  opposite  arm 
was  reported  as  16  minutes.  Tests  for  a cir- 
culating anticoagulant  using  the  recalcifica- 
tion times  of  mixtures  of  the  patient’s  plasma 
with  normal  plasma  were  positive  (Fig.  2). 


Patient’s  plasma,  cc 

0 

0.1 

0,1 

0.1 

0.4 

0.2 

Normal  plasma,  cc 

0,2 

0.4 

0.2 

0.1 

0.1 

0 

Calcium  chloride  0.025M  0.2 

0.2 

0.2 

0.2 

0.2 

0.2 

Clotting  time,  seconds 

135 

140 

290 

390 

450 

580 

FIG.  2 

Prolongation  of  Recalcification  Time  of  Normal  Plasma 
by  Circulating  Anticoagulant  (Case  6) 


He  was  then  started  on  cortisone,  and  plas- 
ma infusions  were  discontinued.  The  pati- 
ent’s pain  required  considerable  narcotic 
medication,  but  there  was  gradual  improve- 
ment. A repeat  test  for  circulating  anticoag- 
ulants showed  no  beneficial  effects  from  the 
adrenal  steroid.  Cortisone  was  therefore  dis- 
continued in  step-wise  fashion  as  terminal 
ACTH  stimulation  was  administered.  Recur- 
rent severe  pain  and  increased  swelling  of 
the  joint  were  treated  with  large  infusions 
of  plasma  which  again  failed  to  restore  the 
clotting  time  to  normal.  Plasma  administra- 
tion seemed  useless  and  was  discontinued. 
Very  gradual  improvement  occurred  and  dis- 
charge was  possible  after  a total  of  six  weeks 
hospitalization. 

The  patient  did  well  for  the  following  six 
months.  Then  rehospitalization  was  necessi- 
tated by  severe  epistaxis.  This  was  controlled 


by  conservative  means  without  administra- 
tion of  plasma.  He  had  five  subsequent  short 
admissions  for  recurring  hemarthroses,  all  of 
which  slowly  responded  to  conservative 
therapy  without  administration  of  plasma. 
His  final  admission  on  July  2,  1956,  was  neces- 
sitated by  symptoms  due  to  an  upper  respira- 
tory infection  with  frontal  sinusitis.  He  was 
placed  on  penicillin  orally,  but  on  the  sec- 
ond hospital  day  his  temperature  increased  to 
101.8°,  he  continued  to  complain  of  frontal 
headache,  was  nauseated,  and  vomited  sev- 
eral times.  His  venous  clotting  time  exceed- 
ed one  hour  and  fifteen  minutes.  On  the 
morning  of  the  third  hospital  day  the  patient 
was  found  to  be  stuporous  and  showed  wide 
dilatation  of  the  right  pupil,  left  hemiplegia, 
and  a positive  Babinski  on  the  left.  In  an  at- 
tempt to  overwhelm  the  circulating  anti- 
bodies, hoping  thereby  to  correct  the  clotting 
defect  for  a few  minutes  at  least,  200  cc.  of 
plasma  were  given  very  rapidly,  and  a trans- 
fusion of  fresh  blood  was  started.  The  pati- 
ent expired  while  this  was  being  adminis- 
tered. Necropsy  revealed  massive  hemor- 
rhage into  the  right  frontal  lobe. 

Comment. — Development  of  a circulating 
anticoagulant  is  one  of  the  most  dreaded  com- 
plications occurring  in  hemophilia  and  oc- 
curs in  five  per  cent  of  such  patients”.  The 
patient  presumably  develops  antibodies 
against  the  very  globulin  he  lacks.  Most 
writers  feel  that  the  development  of  an  anti- 
coagulant is  in  some  way  associated  with  fre- 
quency of  plasma  infusion Attempt- 
ed “prophylactic”  administration  of  plasma 
at  weekly  intervals  is  therefore  discouraged. 

The  presence  of  a circulating  anticoagulant 
is  detected  simply  by  mixing  equal  quantities 
of  the  patient’s  blood  (or  plasma)  with  equal 
quantities  of  normal  blood  (or  plasma)  and 
determining  the  prothrombin  consumption 
(or  clotting  time)  of  the  mixture.  If  an  ab- 
normal result  is  obtained,  an  anticoagulant 
is  present.  The  concentration  of  the  anti- 
body may  be  so  high  that  it  can  inactivate 
large  quantities  of  AHG  present  in  transfused 
plasma.  It  has  been  suggested  that  faint  hope 
of  benefit  lies  in  the  rapid  administration  of 


60 


J.  M.  A.  ALABAMA 


MANAGEMENT  OF  HEMOPHILIA 


a large  amount  (2,000  cc.)  of  plasma.  Tem- 
porarily diluting  and  neutralizing  the  anti- 
bodies may  allow  relatively  normal  coagu- 
lation to  occur  for  a brief  time  with  cessation 
of  bleeding.  If  this  fails,  further  plasma  of- 
fers nothing  and  will  only  raise  the  titer  of 
anticoagulant  higher”.  Bank  blood  (which 
is  deficient  in  AHG)  and  washed  erythro- 
cytes are  then  preferable  to  fresh  whole  blood 
or  plasma.  If  no  antihemophilic  factor  in 
the  form  of  fresh  blood  or  plasma  is  admin- 
istered for  a period  of  weeks  to  months,  the 
antibody  titer  falls.  A high  antibody  titer, 
however,  quickly  recurs  when  further  ad- 
ministration of  plasma  is  necessitated  by 
hemorrhage.  Administration  of  adrenal  cor- 
tical hormones  has  proven  ineffective  when 
an  anticoagulant  develops,  despite  one  report 
to  the  contrary’’’.  From  a practical  stand- 
point, control  of  internal  hemorrhage  is  im- 
possible when  this  complication  occurs,  and 
the  outlook  is  therefore  extremely  poor. 


Discussion 

Consideration  of  diagnostic  accuracy  and 
technics  of  the  various  tests  used  in  diagnosis 
of  the  hemophilioid  disorders  is  beyond  the 
scope  of  this  discussion.  The  degree  of  de- 
ficiency in  coagulation  protein  in  these  dis- 
eases may,  however,  vary  from  a very  slight 
decrease  below  normal  to  almost  complete 
absence — with  attendant  difficulty  or  ease 
in  diagnosis,  as  the  case  may  be-".  At  times 
the  coagulation  abnormality  in  borderline 
cases  may  be  demonstrable  only  when  active 
hemorrhage  depletes  the  critical  protein  and 
outstrips  the  patient’s  limited  ability  to  re- 
place it-h  The  degree  of  globulin  deficiency 
appears  to  be  quantitatively  transmitted  in 
a given  family--.  As  a result,  the  clinical 
severity  of  the  disorder  is  about  the  same  in 
all  affected  members.  Despite  a negative 
family  history  of  hemophilia  or  abnormal 
bleeding  in  many  patients,  it  seems  more  like- 
ly that  the  defect  is  inherited  than  the  result 
of  mutation-”. 

We  strongly  advise  that  a normal  control 


be  run  simultaneously  with  every  test  ap- 
plied to  a patient’s  blood  or  plasma.  Each 
laboratory  should  establish  its  own  normal 
results  for  every  procedure  used.  Like  Con- 
ley, we  have  found  that  blood  from  normal 
individuals  often  shows  relatively  little  pro- 
thrombin consumption  during  clotting  unless 
there  has  been  sufficient  contact  with  glass^h 
We  have  seen  normal  people  labeled  as 
“bleeders”  on  the  basis  of  a report  of  poor 
prothrombin  utilization  because  this  fact  was 
not  realized.  In  performing  the  prothrombin 
consumption  test,  we  gently  invert  the  blood 
in  the  glass  tube  25  times  before  coagulation 
and  incubation.  This  accelerates  prothrombin 
consumption  in  normal  blood,  allowing  ready 
distinction  between  normal  and  hemophilic 
individuals. 

The  future  holds  some  promise,  perhaps,  of 
such  purification  or  synthesis  of  the  proteins 
deficient  in  the  various  hemophiloid  states 
that  they  can  be  used  in  a fashion  similar  to 
insulin  in  diabetes.  As  yet  this  has  not  been 
accomplished.  It  cannot  be  emphasized  too 
strongly  that  the  oral  or  parenteral  admin- 
istration of  various  “hemostatic”  agents,  such 
as  calcium,  vitamin  K,  ascorbic  acid,  estro- 
gens, protamine  sulfate,  toluidine  blue,  fla- 
vonoids,  and  adrenochromes  are  useless.  Lo- 
cal bovine  topical  thrombin  is  only  of  very 
limited  value.  The  factor  deficient  in  hemo- 
philia (AHG)  is  present  in  high  concentra- 
tion only  in  blood  which  has  been  stored  for 
less  than  24  hours.  It  is  best  to  collect  such 
blood  in  plastic  bags  or  silicone  coated  bot- 
tles-’”. AHG  may  be  preserved  and  stored  as 
fresh  plasma  which  is  rapidly  frozen  and 
maintained  at  minus  20°  Centigrade.  Most 
lyophilized  plasma  is  devoid  of  clot-promot- 
ing activity,  though  there  is  one  commercial 
product,  apparently  prepared  with  special 
care,  marketed  under  the  somewhat  mislead- 
ing term  “antihemophilic  plasma”  (Hyland). 

Happily,  plasma  thromboplastin  compon- 
ent (PTC)  and  plasma  thromboplastin  ante- 
cedent (PTA)  are  quite  stable  in  stored  blood 
or  plasma”"-  Unlike  AHG,  they  are  not 
destroyed  or  utilized  during  clotting.  They 
are,  in  fact,  potentiated  by  coagulation,  being 


AUGUST  I960— VOL.  30,  NO.  2 


61 


MANAGEMENT  OF  HEMOPHILIA 


found  in  high  concentration  in  serum.  Serum 
which  has  aged  several  days  has  been  used 
with  excellent  effect  in  treatment  of  these 
hemophilioid  states. 

The  administration  of  plasma  and  blood  al- 
ways carries  the  risk  of  possible  plasma-''^  or 
blood  transfusion  reactions,  and  transmission 
of  homologous  serum  hepatitis-^.  Develop- 
ment of  Rh  antibodies  in  an  Rh-negative  he- 
mophiliac has  followed  administration  of 
plasma  from  Rh-positive  donors^'*.  We  pre- 
fer to  use  plasma  from  donors  of  the  same 
blood  type  as  the  patient,  though  theoreti- 
cally plasma  from  type  AB  blood  should  be 
satisfactory. 

As  illustrated  by  Cases  2 and  5,  expert 
orthopedic  guidance  and  management  of 
these  patients  is  invaluable.  For  detailed 
information  regarding  this  important  aspect 
of  treatment,  the  reader  is  referred  to  recent 
articles  on  the  subject. 

Sn  iinmiry 

1.  Six  cases  are  presented  to  illustrate  and 
emphasize  certain  of  the  clinical  problems 
encountered  in  the  management  of  hemo- 
philia. These  include  diagnostic  difficulty  re- 
sulting from  unsatisfactory  venipuncture, 
differential  diagnosis  between  hemorrhage 
into  a joint  and  acute  pyogenic  synovitis, 
treatment  of  seemingly  minor  head  injury, 
dental  care,  surgical  procedures,  and  devel- 
opment of  a circulating  anticoagulant. 

2.  Some  factors  influencing  the  laboratory 
findings  in  the  hemophilioid  states  and  treat- 
ment of  these  disorders  with  blood  and  plas- 
ma are  briefly  discussed. 

REFERENCES 

1.  Lewis,  J.  H.;  Tagnon,  H.  J.;  Davidson,  C.  S.; 
Minot,  G.  R.;  and  Taylor,  F.  H.  L.:  The  Relation  of 
Certain  Fractions  of  the  Plasma  Globulins  to  the 
Coagulation  Defect  in  Hemophilia.  Blood  1:  166, 
1946. 

2.  Quick,  A.  J.;  Studies  on  the  Enigma  of  the 
Hemostatic  Dysfunction  of  Hemophilia.  Am.  J. 
Med.  Sc.  214:  272,  1947. 


3.  Brinkhous,  K.  M.  and  Graham,  J.  B.:  Hemo- 
philia and  the  Hemophilioid  States.  Blood  9:  254, 
1954. 

4.  Ham,  T.  H.:  A Syllabus  of  Laboratory  Exam- 
inations in  Clinical  Diagnosis.  Harvard  University 
Press,  1951. 

5.  Quick,  A.  J.:  On  the  Nature  and  Diagnosis 
of  Hemophilia.  Blood  9:  265,  1954. 

6.  Hougie,  C.  and  Glover,  H.  M.:  The  Hemo- 
philioid States.  A.M.A.  Arch.  Int.  Med.  103:  239, 
1959. 

7.  Stefanini,  M.  and  Dameshek,  W.:  The  Hem- 
orrhagic Disorders.  Grune  and  Stratton,  New 
York,  1955. 

8.  Rodman,  N.  F.,  Jr.,  Barron,  E.  M.  and  Gra- 

ham, J.  B.:  Diagnosis  and  Control  of  the  Hemo- 
philioid States  with  the  Partial  Thromboplastin 
Time  (PTT)  Test.  Am.  J.  Clin.  Path.  29:  525, 

1958. 

9.  Diamond,  L.  K.  and  Porter,  F.  S.:  The  In- 

adequacies of  Routine  Bleeding  and  Clotting  Times. 
New  Eng.  J.  Med.  259:  1025,  1958. 

10.  De  Palma,  A.  F.:  Guiding  Principles  in  the 
Surgery  of  Hemophilic  Patients,  Progress  in  He- 
matology. Vol.  1,  193,  1956,  Grune  and  Stratton, 
New  York. 

11.  Aggeler,  P.  M.,  Alexander,  B.,  Rosenthal, 

M.  C.,  Tocantins,  L.  M.  and  Dameshek,  W.:  Panel 

in  Therapy  IX.  The  Treatment  of  Hemophilia. 
Blood  11:  81,  1956. 

12.  Rubin,  B.,  Levine,  P.  and  Rosenthal,  M.  C.: 
Complete  Dental  Care  of  the  Hemophiliac.  Oral 
Surg.,  Oral  Med.,  and  Oral  Path.  12:  665,  1959. 

13.  Fleuchaus,  P.  T.:  Prolonged  Hemorrhage 

following  Extraction  in  a Hemophiliac.  Oral  Surg., 
Oral  Med.,  and  Oral  Path.  7:  720,  1954. 

14.  Archer,  W.  H.  and  Zubrow,  H.  J.:  Fatal 

Hemorrhage  Following  Regional  Anesthesia  for 
Operative  Dentistry  in  A Hemophiliac.  Oral  Surg., 
Oral  Med.,  and  Oral  Path.  7:  464,  1954. 

15.  Davidson,  C.  S.,  Epstein,  R.  D.,  Miller,  G.  F., 

and  Taylor,  F.  H.  L.:  Hemophilia.  A Clinical 

Study  of  Forty  Patients.  Blood  4:  97,  1949. 

16.  Richards,  M.  D.  and  Spaet,  T.  H.:  Immuni- 
zation of  Rabbits  Against  Human  Anti-Hemophilic 
Factor  (AHF).  Blood  11:  473,1956. 

17.  Craddock,  C.  G.,  and  Lawrence,  J.  S.:  He- 
mophilia. A Report  of  the  Mechanism  of  the  De- 
velopment and  Action  of  an  Anticoagulant  in  Two 
Cases.  Blood  2:  505,  1947. 

18.  Frommeyer,  W.  B.,  Jr.,  Epstein,  R.  D.,  and 
Taylor,  F.  H.  L.:  Refractoriness  in  Hemophiliacs 
to  Coagulation  Promoting  Agents;  Whole  Blood 
and  Plasma  Derivatives.  Blood  5:  401,  1950. 

19.  Van  Creveld,  S.,  Hoorweg,  P.  G.,  and  Paul- 
sen, M.  P.:  Researches  on  a Circulating  Anticoagu- 
lant in  a Hemophiliac.  II.  Effect  of  Administration 
of  ACTH  and  Cortisone.  Blood  8:  125,  1953. 


62 


J.  M.  A.  ALABAMA 


MANAGEMENT  OF  HEMOPHILIA 


20.  Brinkhous,  K.  M.,  Langdell,  R.  D.,  Penick, 
G.  D.,  Graham,  J.  B.  and  Wagner,  R.  H.:  Newer 
Approaches  to  the  Study  of  Hemophilia  and  He- 
mophilioid  States.  J.  A.  M.  A.  154:  481,  1954. 

21.  Graham,  J.  B.,  McClendon,  W.  W.  and 

Brinkhous,  K.  M.:  Mild  Hemophilia:  An  Allelic 

Form  of  the  Disease.  Am.  J.  M.  Sc.  225:  46,  1953. 

22.  Quick,  A.  J.  and  Hussey,  C.  V.:  Hemophilia: 
Quantitative  Studies  of  the  Coagulation  Defect. 
A.  M.  A.  Arch.  Int.  Med.  97:  524,  1956. 

23.  Quick,  A.  J.:  Hemorrhagic  Diseases.  Lea 

and  Febiger,  Philadelphia,  1957. 

24.  Dick,  F.  W.,  Jackson,  D.  P.,  and  Conley,  C. 
L.:  Surface  as  a Quantitative  Factor  in  Prothrom- 
bin Utilization.  J.  Clin.  Invest.  33:  1423,  1954. 

25.  Rapaport,  S.  I.,  Ames,  S.  B.  and  Mihkelson, 
S.:  The  Levels  of  Antihemophilic  Globulin  and 
Proaccelerin  in  Fresh  and  Bank  Blood.  Am.  J. 
Clin.  Path.  31:  297,  1959. 

26.  White,  S.  G.,  Aggeler,  P.  M.  and  Glenden- 

ing,  M.  B.:  Plasma  Thromboplastin  Component 

(PTC),  A Hitherto  Unrecognized  Blood  Coagula- 


tion Factor.  Case  Report  of  PTC  Deficiency. 
Blood  8:  101,  1953. 

27.  Rosenthal,  R.  L.,  Dreskin,  O.  H.,  and  Rosen- 
thal, N.:  New  Hemophilia-like  Disease  Caused 

by  Deficiency  of  a Third  Plasma  Thromboplastin 
Factor.  Proc.  Soc.  Exper.  Biol,  and  Med.  82: 
171,  1953. 

28.  Crosby,  W.  H.  and  Stefanini,  M.:  Patho- 

genesis of  Plasma  Transfusion  Reaction  with 
Especial  Reference  to  Blood  Coagulation  System. 
J.  Lab.  and  Clin.  Med.  40:  374,  1952. 

29.  Stokes,  J.,  Jr.,  Berk,  J.  E.,  Melamut,  L.  L., 

Drake,  M.  E.,  Barondess,  J.  A.,  Bashe,  W.  J.,  Wol- 
man,  I.  J.,  Farquhar,  J.  E.,  Bevan,  B.,  Drummond, 
R.  J.,  Maycock,  W.  D.,  Capps,  R.  B.,  and  Bennett, 
A.  M.:  The  Carrier  State  in  Viral  Hepatitis. 

J.  A.  M.  A.  154:  1059,  1954. 

30.  Grove-Rasmussen,  M.,  Shaw,  R.  S.,  and 
Dreisler,  N.:  Stimulation  of  Rh  Antibodies  in  an 
Rh-Negative  Patient  with  Hemophilia:  Report  of 
a Case  Developing  After  Repeated  Transfusions 
of  Fresh  Frozen  Plasma  Prepared  from  Rh-Posi- 
tive  Bloods.  New  Eng.  J.  Med.  252:  673,  1955. 


AUGUST  I960— VOL.  30,  NO.  2 


63 


The  Treatmenl  Of  Acute  Head  Injuries 


WALTER  G.  HAYNES.  M.  D. 
Birmingham,  Alabama 


Repeated  discussion,  ad  nauseam,  of  any 
medical  problem  is  justifiable  only  if  there 
has  been  some  progress  in  diagnosis  or  treat- 
ment. The  only  valid  excuse  for  presenting 
a resume  of  the  treatment  of  head  injuries  is 
that  there  are  a few  new  adjuncts  developed 
in  the  last  few  years  which  have  been  help- 
ful. The  early  performance  of  tracheotomy, 
for  more  efficient  suction  of  an  obstructed, 
or  wet,  air  way  has  been  of  benefit.  The  use 
of  a cerebral  dehydrating  agent,  intravenous 
urea,  is  of  great  help.  Urea  for  this  purpose, 
however,  is  not  considered  new,  since  it  was 
given  orally  in  the  early  1940’s.  This  was 
not  practical  and  the  oral  administration  was 
discarded.  However,  since  it  has  been  com- 
bined with  invert  sugar  and  purified  so  that 
it  can  be  given  intravenously,  it  has  become 
sensible  and  efficient. 

The  other  new  aid  in  combating  severe, 
diffuse  brain  damage  with  malignant  cere- 
bral edema,  and  consequent  compromise  of 
vital  centers,  is  hypothermia.  It  is  believed 
that  hypothermia  can  be  safely  used  in  the 
hospital  ward  over  a fairly  long  period  of 
time.  These  subjects  will  be  discussed  in 
more  detail  later. 


Dr.  Haynes  is  a graduate  of  the  University  of 
Illinois  College  of  Medicine,  a Fellow  of  the  Amer- 
ican College  of  Surgeons  and  International  College 
of  Surgeons  and  is  engaged  in  the  practice  of 
neurological  surgery. 


The  treatment  of  all  head  injuries  fall  into 
the  same  general  pattern,  depending  only  on 
the  severity  of  the  diffuse  brain  damage  and 
the  question  of  surgical  intervention. 

The  treatment  of  simple  or  mild  concussion, 
wherein  a patient  has  been  temporarily  ren- 
dered unconscious  for  a few  seconds  to  a few 
hours,  arouses  and  presents  few  complaints 
beyond  that  of  some  headache  and  dizziness 
and  few  signs  beyond  that  of  a nystagmus, 
would  obviously  be  very  little  beyond  symp- 
tomatic treatment.  Observation  overnight, 
usually  in  the  hospital,  or  awakening  at 
stated  regular  intervals  during  the  night  if 
the  patient  is  at  home,  is  indicated.  One  must 
guard  against  acute  hemorrhagic  conditions 
such  as  a middle  meningeal  hemorrhage  or 
an  acute  subdural  hemorrhage.  This  is  best 
carried  on  in  the  hospital,  recording  the  blood 
pressure,  pulse,  responses,  and  other  vital  in- 
formation at  least  every  thirty  minutes,  so 
that  the  nurse  or  attendant  can  be  sure  that 
the  patient  can  be  aroused  at  that  time.  If 
the  patient  is  at  home,  the  family  should  be 
instructed  to  awaken  the  patient  every  thirty 
minutes  or  every  hour  during  the  first  night. 
Naturally,  the  size  and  equality  of  the  pupils 
is  noted  at  that  time,  since  a unilateral  dilata- 
tion of  a pupil  might  indicate  hemorrhage  on 
that  particular  side.  Equally  contracted,  or 
dilated  pupils  are  of  no  particular  importance 
if  they  react  to  light.  This  is  the  basic  reason 
for  the  seemingly  nonsensical  order  of  a 


64 


J.  M.  A.  ALABAMA 


HEAD  INJURIES 


Cerebral  Trauma 

I.  Concussion  (Diffuse  Brain  Damage) 

a.  Mild 

b.  Severe 

1.  With  recovery 

2.  Without  recovery 

II.  Fractures 

a.  Simple  (linear  or  stellate) 

b.  Compound,  and,  or 

c.  Depressed 

d.  Basal 

III.  Hemorrhage 

a.  Subarachnoid 

b.  Subdural 

1.  Acute 

2.  Chronic 

c.  Extradural  (middle  meningeal) 

d.  Intracerebral 

1.  Pontine,  brain  stem,  hypothalamic 

2.  Hemispheric 

IV.  Combined  Injuries 

a.  Shock 

b.  Other  Fractures 

c.  Other  injuries 

1.  Thorax,  abdomen,  burns 

Objectives  of  Treatment  of 
Acute  Head  Injuries 

1.  Observation  for  possible  surgical  inter- 
vention 

2.  Reduction  of  cerebral  edema  and  con- 
trol of  anoxia 

3.  Relief  of  compromised  vital  centers 

4.  Avoidance  of  or  treatment  of  complica- 
tions, such  as  pulmonary  stasis,  renal  shock, 
fluid  or  electrolyte  imbalance 

5.  Surgical  relief  of  hemorrhage,  pressure, 
foraminal  or  incisural  herniation 

6.  Symptomatic  and  harmless  treatment  of 
more  common  complications,  such  as  pain, 
restlessness,  convulsions,  and  temperature 
control 

Surgical  Indications  in 
Acute  Cerebral  Trauma 

I.  Fractures 

a.  Compound 

b.  Depressed 

II.  Hemorrhage 

a.  Subdural — acute 

b.  Extradural 

c.  Intracerebral  (15  to  30  cc.) 


blood  pressure  recording  every  fifteen  to 
thirty  minutes,  which  the  neurosurgeon  us- 
ually requests.  Deepening  coma,  the  advent 
of  a dilated  pupil,  or  a convulsion,  would  be 
of  considerable  importance  in  determining  if 
surgery  is  indicated. 

Treatment  of  severe  concussion,  or  marked 
diffuse  brain  damage  which  might  be  severe 
enough  to  cause  death,  carries  this  a step  fur- 
ther. The  usual  observation  for  signs  of  lo- 
calized damage  to  the  brain,  which  might  be 
caused  by  hemorrhage,  is  still  carried  out.  In 
addition,  we  must  allow  vital  centers  to  func- 
tion with  the  least  possible  oxygen  demand 
so  that  this  patient  can  be  kept  alive  as  long 
as  possible.  This  may  allow  regression  of 
malignant  cerebral  edema  and  even  be- 
ginning resolution  of  the  multiple  petechial 
hemorrhages  scattered  throughout  the  brain 
substance.  This  is  the  crux  of  the  whole 
problem. 

The  patient  with  severe  diffuse  brain  dam- 
age, with  or  without  skull  fracture,  and  with 
or  without  intracranial  hemorrhage  of  any 
consequence,  is  the  most  baffling  problem 
that  is  faced  in  the  treatment  of  acute  head 
injuries. 

It  is  assumed  that  shock,  if  present,  has 
been  treated.  Blood  loss  has  been  replaced. 
Other  fractures  have  been  at  least  immobil- 
ized pending  the  outcome  of  the  more  im- 
portant cerebral  damage.  Other  injuries  such 
as  thoracic,  or  acute  abdominal  injuries, 
might  necessitate  surgical  intervention  super- 
seding cerebral  treatment.  A critical  evalu- 
ation must  take  place  at  this  time,  because 
anesthesia  and  surgery  of  the  thorax  or  ad- 
domen  in  the  face  of  diffuse  brain  damage 
could,  of  course,  be  fatal.  If  it  is  at  all  possi- 
ble this  treatment  is  postponed  pending  the 
outcome  of  the  cerebral  condition. 

The  head  of  the  bed  is  elevated  some  twen- 
ty degrees  to  facilitate  venous  drainage  from 
the  brain,  and,  for  the  same  reason,  the  hos- 
pital gown  is  not  tied  about  the  neck  so  that 
venous  return  is  not  impeded.  These  patients 
usually  require  oxygen  since  the  basic  path- 
ology in  cerebral  damage  is  anoxia  and  edema 


AUGUST  I960— VOL.  30,  NO.  2 


65 


HEAD  INJURIES 


of  the  brain  cells.  These  cells  are  metaboliz- 
ing at  a very  low  rate  and  oxygen  will  help 
improve  the  metabolism  and  thus  reduce  the 
edema  of  the  brain  cells.  Suction  is  particu- 
larly important  because  of  the  marked  exu- 
dation along  the  tracheo-bronchial  tree  and 
the  inevitable  pulmonary  stasis.  Suction 
should  be  carried  out  by  an  experienced  at- 
tendant, either  via  the  nasal  passages  or 
through  the  mouth,  into  the  trachea  and  even 
into  the  larger  bronchii,  by  means  of  a plastic 
or  rubber  catheter.  If  there  is  any  difficulty 
in  carrying  this  out,  or  in  maintaining  proper 
respiratory  exchange,  a tracheotomy  should 
be  done  without  hesitation.  It  is  a good 
axiom  that  a tracheotomy  should  be  done  at 
the  time  one  thinks  of  doing  a tracheotomy. 

Cerebral  dehydrating  agents  are  still  used. 
Sucrose,  which  has  a larger  molecule  and  is 
absorbed  more  slowly  than  glucose,  is  pre- 
ferred. Sucrose  is  given  in  fifty  or  one  hun- 
dred c.c.  doses  of  the  fifty  percent  solution 
intravenously  as  often  as  every  eight  hours. 
It  is,  however,  far  from  being  the  ideal  drug 
because  of  possible  kidney  damage,  although 
this  is  of  secondary  importance.  Until  the 
advent  of  urea  it  was  considered  the  best  de- 
hydrating agent  available.  Caffeine  in  di- 
vided dosages  every  two  hours  is  an  import- 
ant adjunct.  It  has  a two  fold  effect.  It  in- 
creases the  output  of  the  kidneys  thus  ob- 
taining some  cerebral  dehydration.  It  also 
apparently  dilates  the  cerebral  vessels  so  that 
we  get  a better  oxygenation  of  brain  cells.  It 
is  still  of  considerable  value  in  the  treatment 
of  these  conditions. 

Of  late,  however,  urea  has  become  very  im- 
portant in  the  treatment  of  acute  head  in- 
juries. It  should  be  pointed  out,  however, 
that  urea  should  not  be  used  where  there  is 
a danger  of  intracranial  hemorrhage  of  any 
surgical  significance.  Urea  will  decrease  the 
size  of  the  brain  by  at  least  one  quarter  of 
the  brain  volume.  This  is  done  primarily  by 
dehydration  of  brain  cells.  It  is  used  ex- 
tensively in  intracranial  surgery  to  reduce 
the  volume  of  the  brain  in  those  cases  of  ex- 
treme edema  due  to  brain  tumors.  It  takes 
about  an  hour  for  the  maximum  effect  to 


take  place.  Urea  could  be  repeated  every 
eight  hours  if  necessary.  It  has  a sclerosing 
effect  on  the  veins  and  it  has  other  adverse 
side  effects,  none  of  which,  however,  are  of 
particular  importance  when  one  is  dealing 
with  a lethal  condition.  A catheter  should  be 
placed  in  the  bladder  and  a record  kept  of 
the  intake  and  output.  A daily  non-protein- 
nitrogen  is  of  value  in  following  the  progress 
and  efficacy  of  the  urea  administration.  A 
kidney  shut  down  would,  of  course,  be  an  in- 
dication to  stop  urea  administration.  If  the 
basic  problem  of  the  cerebral  damage  is  that 
of  cerebral  edema,  it  can  be  successfully  com- 
bated by  the  above  agents.  Surgery,  such  as 
sub-temporal  decompression  is  of  no  particu- 
lar value,  since  these  fairly  efficient  agents 
are  available. 

Fluid  and  electrolyte  balance  is  maintained 
in  these  comatose  patients  by  intravenous  or 
gastric  administration.  Fluid  intake  is  not 
limited,  since  proper  hydration  and  proper 
electrolyte  concentration  is  important  to  the 
unit  as  a whole.  The  brain  can  be  selectively 
dehydrated  by  other  means. 

Restlessness  and  post-traumatic  delirium 
are  common  complications.  These  can  be 
controlled  now  much  more  efficiently  by  the 
use  of  chlorpromazine  derivatives  such  as 
Sparine®,  contrasted  to  barbiturates  which 
caused  some  depression  of  the  vital  centers. 
It  goes  without  saying  that  narcotics  are  not 
used  since  vital  centers  controlling  respira- 
tion and  cardiac  action  are  already  compro- 
mised by  either  petechial  hemorrhages, 
edema,  or  constriction  of  that  area  by  hernia- 
tion of  the  cerebellar  tonsils  at  the  Foramen 
Magnum,  or  the  temporal  lobes  through  the 
incisura  of  the  tentorium. 

Convulsions  are  of  serious  import  and 
might  indicate  cortical  damage  due  to  an  ex- 
panding lesion  such  as  a hematoma,  either 
subdural  or  extradural.  We  must,  however, 
also  remember  that  convulsions  can  be 
caused  by  cerebral  lacerations  and  contusions 
which  are  not  surgical.  The  treatment  of  the 
convulsion  in  its  immediate  phase,  while  one 
is  determining  the  cause  of  the  convulsion,  is 
the  same  as  the  treatment  of  convulsions  any- 


66 


J.  M.  A.  ALABAMA 


HEAD  INJURIES 


where.  Barbiturates  are  still  used  for  this 
problem  including  Nembutal®  suppositories. 
Intravenous  Dilantin  Sodium,  however,  can 
now  be  administered  rapidly  and  give  im- 
mediate protection  without  depression. 

The  treatment  of  pain  is  not  of  much  im- 
portance in  patients  with  severe  diffuse  brain 
damage  because  they  are  in  coma  and  their 
pain  is  not  at  a cortical  level.  We  can  use 
the  usual  agents  up  to,  and  even  including, 
small  doses  of  codeine  in  patients  with  lesser 
brain  damage  who  are  semi-comatose,  or 
awake. 

Temperature  control  is  of  great  importance 
since  hemorrhages  into  the  mid-brain,  pons 
or  hypothalamus,  even  though  petechial  and 
small,  will  notoriously  cause  a rise  in  temper- 
ature up  to  and  even  exceeding  107  degrees 
Fahrenheit.  Aspirin  is  used  by  rectum  in 
dosages  up  to  thirty  grains.  Tepid  or  cold 
sponges  with  water  or  alcohol  and  cold  ene- 
mas are  used  when  necessary  to  maintain 
temperature  control. 

Hypothermia 

This  brings  up  the  point  of  the  use  of  hy- 
pothermia in  patients  with  severe  diffuse 
brain  damage.  Malignant  cerebral  edema 
and  multiple,  diffuse,  petechial  hemorrhaged 
may  have  compromised  vital  centers  so  that 
there  is  either  a marked  tachycardia  or  a 
marked  bradycardia,  a marked  hyperpnea, 
or  even  apnea,  and  a very  high  temperature. 
Hypothermia,  if  judiciously  used,  may  save 
a few  lives. 

The  fact  that  these  measures  are  saving 
some  lives  that  would  have  been  lost  without 
the  use  of  them  could  be  debated  on  the 
grounds  of  saving  hopeless  neurologic  crip- 
ples. This  seems  to  be  outside  the  field  of 
medicine,  belonging  more  in  the  field  of 
philosophy  or  theology.  The  physician’s  role 
is  to  maintain  the  spark  of  life  as  long  as 
possible.  This  reasoning,  possibly  fallacious, 
has  more  basis  in  fact,  because  we  repeatedly 
have  seen  the  patient,  apparently  a hopeless 
neurological  cripple,  as  the  result  of  severe 


brain  damage,  slowly  recover  over  a period 
of  a year  to  the  point  where  he  is  socially 
acceptable  and  can  be  employed  in  a gainful 
occupation.  Therefore,  it  cannot  be  said  that 
these  patients,  pitiful  though  they  may  seem 
in  the  first  few  months  of  recovery,  will  not 
eventually  recover. 

It  has  been  argued  that  hypothermia  has 
no  place  on  the  ward  without  adequate  con- 
trol by  a trained  anesthesiologist.  The  use 
of  an  endotracheal  tube  may  sometimes  be 
very  necessary,  but  anesthesia  obviously  is 
not  necessary  in  a deeply  comatose  patient. 
It  is  believed  that  the  level  of  temperature 
can  be  safely  kept  at  a reasonably  low  level 
by  a trained  technician  in  attendance.  A 
constant  recording  thermometer,  with  the 
electrode  inserted  rectally,  is  a necessity.  One 
may  keep  the  temperature  at  a reasonable 
level,  which  in  the  case  of  a head  injury, 
should  not  drop  below  90  degrees  and  should 
preferably  be  kept  about  93  degrees  Fahren- 
heit. 

Hypothermia  may  be  obtained  and  main- 
tained by  the  application  of  ice  packs  and 
cold  wet  cloths  to  the  body  with  a fan  blow- 
ing over  the  patient.  This  will  reduce  the 
temperature  in  about  eight  hours  to  the  de- 
sired level.  It  must  be  remembered  that  this, 
too,  will  cause  a reduction  of  the  brain  vol- 
ume and  therefore  should  not  be  used  where 
there  is  fear  or  recognition  of  surgical 
hemorrhage. 

The  prime  function  of  hypothermia  is  to 
allow  the  brain  cells  to  function  at  a lower 
rate  of  metabolism,  or  oxygenation.  It  must 
also  be  remembered  that  cerebral  edema  is 
at  its  height  on  the  third  day.  Hypothermia, 
therefore,  to  be  effective  must  be  maintained 
for  at  least  seventy-two  hours.  The  tempera- 
ture should  then  be  allowed  to  return  to 
normal. 

It  is  not  unusual  during  this  period  of  time 
for  the  patient  to  need  a ventilator  using  an 
endotracheal  tube,  or  even  a tracheotomy. 
The  patient  is  actually  living  with  artificial 
respiration  in  a state  of  hypothermia.  This 
should  allow  at  least  the  cerebral  edema  to 


AUGUST  I960— VOL.  30,  NO.  2 


67 


HEAD  INJURIES 


subside  so  that  if  the  vital  centers  are  not 
actually  destroyed  the  damage  may  resolve 
in  seventy-two  hours  and  the  patient  may 
recover. 

During  the  period  of  hypothermia  the  anes- 
thesiologist should  be  used  in  consultation. 
A strict  record  of  vital  functions  should  be 
maintained.  An  indwelling  catheter  should 
be  in  place  in  the  urinary  bladder  so  that 
the  intake  and  output  can  be  adequately 
measured. 

Definitive  Approach 

Surgical  relief  of  hemorrhage,  or  pressure 
on  the  brain,  or  relief  of  foraminal  or  in- 
cisural  herniation  is  not  common  but  urgent 
when  diagnosed. 

It  is  common  practice  in  many  clinics  to 
routinely  place  bilateral  burr  holes  to  rule 
in  or  out  intracranial  hemorrhage  on  any 
severe  head  injury.  This  is  particularly  true 
in  Boston,  where  Dr.  Munro  has  carried  it 
out  for  years.  It  is  advocated  by  many  men 
that  the  tentorium  be  incised  to  relieve  the 
incisural  herniation  which  compromise  of  the 
vital  centers.  This  has  been  carried  a step 
further  by  some  surgeons  who  actually,  by 
means  of  suction,  resect  the  hippocampal 
gyrus  on  either  side  to  give  relief  of  this 
compression.  Both  of  these  measures  seem 
heroic,  and  the  practicing  neurosurgeon  will 
carry  these  measures  out  only  as  indicated. 

The  surgical  treatment  of  compound  skull 
fractures  is  only  repair  of  the  scalp  itself 
unless  there  is  depression  of  the  skull  frac- 
ture. A depressed  skull  fracture,  however, 
should  be  repaired  as  soon  as  the  patient’s 
condition  permits  and,  indeed,  because  of  the 
frequent  accompanying  subdural  hematoma, 
may  be  necessary  at  an  earlier  stage  than  one 
would  prefer.  Elevation  of  the  depressed 
fracture  is  a relatively  simple  procedure  and 
may  be  carried  out  under  local  anesthesia 
with  mere  elevation  of  the  bone  fragment. 
If  the  dura  is  torn,  it  is  repaired.  If  there 
is  a hematoma  underlying  this  point  of  de- 
pression it  is  removed  at  that  time. 


Recognition  of  Hemorrhage 

The  main  indication  for  surgery  in  the 
acute  phase  is  that  of  hemorrhage.  This 
hemorrhage  is  either  subdural,  extradural 
(middle  meningeal),  or  intracerebral.  Other 
forms  of  intracranial  hemorrhage,  following 
head  injury,  are  not  surgical. 

Recognition  of  a hemorrhage  is  important. 
The  usual  picture  is  that  of  a patient  with 
deepening  coma  following  a head  injury. 
There  is  slowing  of  the  pulse  rate  and  an 
increase  in  the  systolic-diastolic  gap,  and 
possibly  a slowing  of  the  respiratory  rate. 
Add  localizing  signs  such  as  a hemiparesis 
or  progressive  hemiplegia,  possibly  with  di- 
lated pupil  on  one  side,  and  we  have  the 
indications  for  immediate  surgical  interven- 
tion. 

Spinal  puncture  in  these  cases  may  be  of 
some  academic  value  but  of  very  little  practi- 
cal significance.  The  presence  or  absence  of 
xanthrochromic  or  blood  tinged  spinal  fluid 
is  of  no  particular  significance.  Lumbar 
puncture  in  a basilar  skull  fracture  in  a pa- 
tient bleeding  from  an  ear  would  only  con- 
firm the  presence  of  subarachnoid  bleeding 
and  make  the  diagnosis  of  a basal  skull  frac- 
ture obvious,  a fact  which  is  already  known 
because  the  patient  is  bleeding  from  the  ear. 
All  in  all,  lumbar  puncture  is  not  an  import- 
ant diagnostic  aid  and  certainly  has  very 
little,  if  any,  place  in  the  treatment  of  head 
injuries. 

It  is  difficult  to  distinguish  between  an 
acute  subdural  hematoma  and  an  extradural, 
or  middle  meningeal,  hematoma.  Theoreti- 
cally, one  should  be  able  to  do  this  because 
a subdural  hematoma  is  slowly  formed  by 
venous  bleeding  and  there  should  be  a more 
insidious  process  with  a prolonged  period  of 
deepening  of  coma  and  development  of  neu- 
rological signs. 

Extradural  hemorrhage,  usually  due  to  a 
tear  of  the  middle  meningeal  artery,  is  brisk 
and  arterial.  Time  is  of  the  essence.  This 
diagnosis  must  be  made  quickly  and  surgery 
instituted  as  an  emergency  measure.  Bleed- 


68 


J.  M.  A.  ALABAMA 


HEAD  INJURIES 


ing  must  be  stopped  and  the  hematoma  evac- 
uated. Torsion  of  the  brain  and  the  brain 
stem,  due  to  the  large  clot  compressing  the 
brain,  causes  petechial  hemorrhages  in  the 
mid  brain  and  pons  and  frequently  ends 
fatally. 

The  mortality  rate  of  both  of  these  con- 
ditions is  exceedingly  high,  probably  as  much 
as  60  or  70  percent.  If  necessary,  however, 
surgical  intervention  is  combined  with  the 
treatment  outlined  we  may  reduce  this  pro- 
hibitive death  rate  to  a more  reasonable  fig- 
ure. 

The  symptomatology  of  an  extradural 
hematoma  is  well  known.  Frequently  fol- 
lowing a rather  trivial  head  injury  the  pa- 
tient may  be,  or  may  not  be,  unconscious  for 
a few  seconds  or  a few  minutes,  then  awaken 
and  move  about.  This  moving  apparently 
causes  a renewal  of  the  bleeding  from  the 
artery.  The  patient  becomes  unconscious 
once  more  and  rapidly  develops  a dilated 
fixed  pupil  on  the  side  of  the  hemorrhage  and 
usually  a hemiparesis,  with  increased  re- 
flexes, on  the  opposite  side.  One  must  re- 
member that  these  neurological  signs  are  not 
infallible  since  the  brain  may  be  compressed 
against  the  opposite  edge  of  the  tentorium 
and  give  ipselateral  neurological  signs.  For 
that  reason  bilateral  burr  holes  are  always 
placed. 

Late  Approach 

The  treatment  of  the  delayed  complications 
of  head  injuries  such  as  chronic  subdural 
hematoma,  pneumocephalus,  cerebrospinal 
fluid  leakage,  convulsions,  porencephalic 
cysts,  and  many  other  conditions  which  fol- 
low head  injuries  have  deliberately  not  been 
discussed  here  because  one  has  time  to  evalu- 
ate these  when  the  patient’s  life  is  not  in 
danger.  The  treatment  of  the  acute  head  in- 
jury has  become  so  much  of  a problem  to  the 
practitioner,  as  well  as  to  the  neurosurgeon, 
that  the  principles  as  outlined  above  seem  of 
paramount  importance.  It  is  not  claimed  that 
these  exact  drugs  or  methods  are  the  only 


ones  that  should  be  used.  There  is  great 
room  for  latitude  here,  but  the  above  outline 
seems  a reasonable,  practical  method  of  treat- 
ment. 

One  will  note  that  the  discretion  of  when 
to  take  x-rays  of  the  skull  has  not  been  dis- 
cussed. This  is  not  of  importance.  It  is  ob- 
viously foolish  to  move  a moribund  patient 
to  an  x-ray  department,  with  consequent 
manipulation  of  the  head  in  order  to  reveal  a 
simple  linear  fracture  or  no  fracture  at  all. 

In  these  days  of  legal  complications  and  al- 
most inevitable  impending  lawsuits,  it  is  wise 
to  record  an  electroencephalogram  as  soon  as 
the  patient  is  conscious.  While  it  is  true  that 
fifteen  percent  of  the  general  population  has 
an  abnormal  electroencephalogram,  the  ab- 
normal electroencephalogram  in  a patient 
who  has  suffered  a head  injury  is  important 
if  the  follow  up  electroencephalogram  some 
three  weeks,  and  then  again  some  three 
months,  later  shows  resolution.  This  would 
indicate  that  the  abnormal  electroencephalo- 
gram is  due  to  brain  injury  rather  than  to  the 
fixed  abnormality  found  in  the  fifteen  per- 
cent of  the  population. 

One  must  also  remember  that  an  abnormal 
electroencephalogram  does  not  necessarily 
predict  the  advent  of  convulsions  due  to  brain 
injury.  This  is  a long  and  technical  subject 
which  should  be  discussed  as  a sequelae  of 
head  injuries. 

Conclusion 

An  outline  as  to  the  types  of  cerebral 
trauma,  the  indications  for  surgical  inter- 
vention, and  the  objectives  of  treatment  of 
acute  head  injuries  has  been  presented. 

Some  emphasis  has  been  placed  upon  the 
judicious  use  of  intravenous  urea  as  a cere- 
bral decongestant  and  the  use  of  hypothermia 
in  those  brains  which  have  been  severely 
damaged,  and  in  those  patients  who  would 
probably  expire  without  the  use  of  this 
method.  It  is  not  advocated  that  hypother- 
mia, or  urea,  be  used  indiscriminately  but 
that  they  should  be  reserved  for  those  severe- 


AUGUST  I960— VOL.  30,  NO.  2 


69 


HEAD  INJURIES 


ly  damaged  brains  with  significantly  com- 
promised vital  centers.  It  should  be  remem- 
bered that  hyopthermia  carries  more  than  a 
little  hazard  and  that  constant  attendance, 
observation,  and  adjustment  of  the  tempera- 
ture must  be  carried  out.  (Cardiac  arrhyth- 
mias are  frequently  encountered  when  the 
temperature  drops  below  93  degrees,  and 
while  not  necessarily  an  indication  for  termi- 


nation of  hypothermia  might  become  such  if 
persistent.) 

It  is  particularly  pointed  out  that  while  the 
indications  for  surgery  are  few  in  head  in- 
juries, they  are  immediate.  Constant  obser- 
vation of  the  patient  with  a head  injury  must 
be  carried  out  so  that  intracranial  bleeding 
can  be  detected  and  arrested  at  the  earliest 
possible  stage. 


70 


J.  M.  A.  ALABAMA 


Fifty  Years  Of  Medicine  In  Retrospect 


RALPH  C.  WILLIAMS,  M.  D. 
Atlanta,  Georgia 


The  opportunity  of  addressing  this  fine 
group  of  alumni  of  the  School  of  Medicine  of 
the  University  of  Alabama  and  the  Medical 
College  of  Alabama  is  an  honor  that  is  deep- 
ly appreciated.  No  man  can  be  oblivious  to 
the  unusual  privilege  of  appearing  before  this 
distinguished  body  of  physicians  who  have 
gone  out  from  the  medical  school  that  was 
here  in  Mobile  and  the  medical  college  that 
is  now  in  Birmingham.  May  I assure  you 
that  I am  keenly  aware  of  how  fortunate  I 
am  to  be  a participant  in  your  meeting. 

Here  on  this  occasion  are  assembled  physi- 
cians who  have  attained  distinction,  recog- 
nition and  success  in  many  fields  of  medical 
endeavor.  You  have  gathered  from  many 
towns  and  cities  throughout  Alabama  and 
several  adjoining  states.  I am  delighted  to 
have  the  opportunity  of  being  with  you  and 
renewing  contact  with  good  friends  of  the 
years  that  are  past. 

By  a fortunate  circumstance  this  date  and 
place  coincide  closely  with  the  fiftieth  anni- 
versary of  the  graduation  of  the  class  of  1910 
from  the  Medical  School  of  the  University  of 
Alabama  here  in  Mobile  on  April  18  of  that 


Dr.  Williams  is  Assistant  Surgeon  General  of  the 
United  States  Public  Health  Service  (Retired). 
He  has  been  with  the  Georgia  Department  of  Pub- 
lic Health  since  1951.  He  is  Public  Health  Re- 
search Coordinator. 

Presented  at  the  annual  meeting  of  the  Medical 
Alumni  Association  of  the  University  of  Alabama, 
April  22,  1960,  Mobile,  Alabama. 

AUGUST  I960— VOL.  30,  NO.  2 


year.  I have  the  honor  to  be  a member  of 
that  class.  Forty-one  of  us  received  our  med- 
ical degree  at  that  time,  ten  of  us  still  sur- 
vive. From  here  we  ventured  forth  fifty 
years  ago  as  young  fledglings  in  medicine. 

It  is  important  that  at  intervals  we  pause 
long  enough  to  take  inventory  of  the  pres- 
ent, evaluate  our  progress,  and  prepare  for 
the  future.  The  celebration  of  the  golden 
anniversary  of  the  graduation  of  a medical 
class  is  a fitting  occasion  for  us  to  pause  to 
review  the  past  and  look  forward  toward 
what  the  future  may  bring. 

Medical  Background  of 
Fifty  Years  Ago 

In  1910,  diseases  that  are  now  almost  un- 
known were  then  quite  common.  Malaria 
was  occurring  annually  in  hundreds  of  per- 
sons throughout  this  state.  Cases  of  malaria 
then  were  often  seen  in  the  teaching  wards 
of  the  City  Hospital  here  in  Mobile.  Typhoid 
fever  was  prevalent.  Literally  hundreds  of 
cases  of  smallpox  occurred  each  year  in  the 
United  States.  We  had  our  proportionate 
share  of  these  cases  in  Alabama.  The  last 
epidemic  of  yellow  fever  in  the  United  States 
had  occurred  only  five  years  previously  in 
the  neighboring  city  of  New  Orleans. 

The  yellow  fever  epidemic  of  1905  was  un- 
usual in  many  ways  but  the  outstanding  fact 
is  that  this  was  the  last  outbreak  of  yellow 

71 


FIFTY  YEARS  OF  MEDICINE 


fever  in  the  United  States.  The  first  cases 
of  this  epidemic  appeared  in  New  Orleans 
on  July  21  of  that  year.  The  epidemic  was 
brought  under  control  and  declared  to  be 
terminated  on  October  26,  1905.  This  was 
before  the  first  frost  of  the  season.  The  first 
killing  frost  that  year  in  New  Orleans  was 
on  December  3rd.  For  many  years  the  first 
killing  frost  had  been  considered  to  be  the 
factor  that  terminated  an  epidemic  of  yellow 
fever. 

The  official  records  of  the  U.  S.  Public 
Health  Service  show  that  several  cases  of  yel- 
low fever  occurred  in  Alabama  in  1905.  Four 
cases  reported  were  on  the  steamship  Co- 
lumbia from  Colon  and  La  Boca.  They  were 
recognized  at  the  Mobile  Bay  Maritime  Quar- 
antine Station  on  July  24th.  One  case  was 
reported  at  Montgomery,  Alabama  on  July 
28.  The  last  two  cases  were  at  Castleberry, 
Alabama  on  October  15th.  Both  of  these 
cases  died.  During  the  1905  epidemic  in  New 
Orleans  there  were  3,404  reported  cases  and 
452  deaths.  Thus  passed  from  the  scene  in 
the  United  States  the  dread  specter  of  yellow 
fever  that  for  almost  two  hundred  years  had 
exacted  from  residents  of  this  area  an  ap- 
preciable toll  each  year  in  sickness  and  death. 
Several  of  the  epidemics  of  yellow  fever  in 
Alabama  resulted  in  large  numbers  of  deaths. 
The  files  of  the  newspapers  published  in  the 
state  in  1870’s,  1880’s,  and  1890’s  give  ample 
evidence  of  the  panic  and  fear  that  gripped 
the  people  during  those  earlier  outbreaks  of 
yellow  fever. 

Other  diseases  prevalent  not  only  in  Ala- 
bama in  1910  but  throughout  the  South  in- 
cluded pellagra,  tuberculosis,  and  the  ve- 
nereal diseases.  Although  diphtheria  anti- 
toxin was  in  common  use  then,  large  doses 
were  required  and  we  did  not  have  the  pres- 
ent day  refinements  or  the  preventive  use  of 
toxoid  or  toxin-antitoxin  with  which  we  are 
familiar  today. 

The  discovery  of  the  treponema  pallidum 
by  Schaudinn,  the  pale  spirochete,  the  causa- 
tive organism  of  syphilis  had  been  announced 
only  five  years  previously  (1905).  The  Was- 
sermann  blood  serum  reaction  for  the  diag- 


nosis of  syphilis  had  only  been  recently  re- 
ported (1906). 

There  have  been  notable  gains  in  all  fields 
of  medical  science  since  the  era  of  1910.  There 
are  indications  that  the  future  holds  as  much 
in  the  way  of  change  and  advance  as  we  have 
seen  in  the  past  fifty  years.  That  captain  of 
the  men  of  death — pneumonia-was  a common 
and  dangerous  foe  then.  Although  we  still 
have  pneumonia  with  us,  it  does  not  now 
present  the  problems  often  times  hopeless, 
which  we  wrestled  with  fifty  years  ago.  The 
ten  leading  causes  of  death  in  the  United 
States  in  1910  were  as  follows: 

1.  Heart  diseases 

2.  Pneumonia  and  influenza 

3.  Tuberculosis,  all  forms 

4.  Diarrhea,  enteritis  and  ulceration  of  in- 
testines 

5.  Nephritis,  all  forms 

6.  Intracranial  lesions  of  vascular  origin 

7.  Cancer  and  other  malignant  tumors 

8.  Accidents 

9.  Prematurity 

10.  Diseases  peculiar  to  early  infancy  other 
than  congenital  malformations 

You  will  note  that  pneumonia  and  influ- 
enza hold  second  place  with  tuberculosis  be- 
ing third.  Cancer  and  accidents  were  in  sev- 
enth and  eighth  place  respectively.  The  ten 
leading  causes  of  death  fifty  years  later  in- 
cludes some  of  those  diseases  recorded  in  the 
list  of  1910,  but  the  order  of  occurrence  has 
changed  and  other  causes  have  moved  up  in- 
to the  list  of  the  first  ten  causes  of  death.  For 
1960  the  list  would  probably  be  in  this  order: 

1.  Heart  diseases 

2.  Cancer 

3.  Vascular  lesions  affecting  central  nerv- 
ous system 

4.  Accidents 

5.  Certain  diseases  of  early  infancy 

6.  Influenza  and  pneumonia 

7.  General  arteriosclerosis 

8.  Diabetes  mellitus 

9.  Congenital  malformations 

10.  Cirrhosis  of  liver 

11.  Suicide 


72 


J.  M.  A.  ALABAMA 


FIFTY  YEARS  OF  MEDICINE 


This  list  is  actually  based  on  the  reports 
for  1958,  the  latest  year  for  which  final  sta- 
tistics are  available.  Please  note  that  cancer 
is  now  in  second  place,  that  pneumonia  and 
influenza  have  dropped  to  sixth  place.  Ac- 
cidents have  risen  to  fourth  place.  Tubercu- 
losis is  no  longer  one  of  the  first  ten  causes 
of  death  in  the  United  States.  These  changes 
reflect  important  advances  in  health  con- 
ditions and  indicate  where  our  current  health 
problems  are  found. 

Statistics  of  the  principle  causes  of  death 
in  Alabama  in  1910  are  not  available.  How- 
ever in  the  adjoining  state  of  Georgia  where 
I now  reside,  the  following  comparison  of 
the  number  of  deaths  from  certain  diseases 
in  1920  and  with  the  present  is  of  interest. 


DEATHS  FROM  SPECIFIED  CAUSES.  GEORGIA. 
1920  AND  1958 


Cause  of  Death  1920  1958 


Typhoid  fever  and  paratyphoid.  549  0 

Malaria  . 559  0 

Pellagra  . 432  10 

Influenza  . 2,581  208 

Pneumonia  . . 2,766  1,214 

Tuberculosis  2,362  268 

Syphilis  204  98 

Diarrhea  and  enteritis 

under  2 years  1,252  29 

Diphtheria  401  9 

Scarlet  fever 32  0 

Meningitis,  all  forms 172  81 

Smallpox  — 3 0 


In  a note  published  in  a medical  journal  in 
1910  the  ten  most  important  drugs  then  in 
common  use  were  listed  as  follows: 

1.  Ether 

2.  Morphine 

3.  Digitalis 

4.  Digitalis  and  its  derivatives 

5.  Smallpox  vaccine 

6.  Iron 

7.  Quinine 

8.  Iodine 

9.  Alcohol 

10.  Mercury 


Such  a list  now  would  include  only  a few 
of  those  items  listed  above.  There  might  be 
some  technical  differences  of  opinion,  but 
for  1960  the  list  would  probably  include  the 
following: 

1.  Ether  and  other  anesthetics 

2.  Antibiotics 

3.  Antiseptics,  including  alcohol  and  io- 
dine 

4.  Digitalis  and  its  derivatives 

5.  Hormonal  substances 

6.  Immunizing  agents 

7.  Oxygen 

8.  Parenteral  fluids 

9.  Radio  therapy  (radio  substances.  X-ray 
and  radium) 

10.  Morphine  and  other  opium  derivatives, 
barbiturates 

11.  Substitution  products  (insulin,  thy- 
roid extract,  liver  extract) 

12.  Vitamins 

In  comparing  these  two  lists  of  commonly 
used  drugs  or  related  substances,  we  are  re- 
minded of  the  tremendous  progress  made  in 
the  effective  use  of  therapeutic  agents.  Im- 
provement of  precision  and  accuracy  in  diag- 
nosis have  contributed  greatly  to  efficacy  of 
treatment. 


Fifty  Years  of  Medical  Progress 

To  have  said  in  1910  that  it  would  be  rela- 
tively simple  in  1960  to  have  breakfast  in 
Paris,  lunch  in  New  York  City  and  a round  of 
golf  in  Mobile,  Alabama  all  in  the  same  day 
would  have  been  good  grounds  to  think  the 
person  making  the  statement  was  out  of 
touch  with  reality.  Yet  today  this  is  actually 
possible  through  the  tremendous  advances  in 
aviation. 

The  same  dramatic  changes  have  taken 
place  in  the  science  and  practice  of  medicine 
in  the  past  half  century.  Diseases  formerly 


AUGUST  I960— VOL.  30,  NO.  2 


73 


FIFTY  YEARS  OF  MEDICINE 


considered  inevitable  have  disappeared.  Sur- 
gical procedures  beyond  the  flight  of  fancy 
are  now  routine.  Drugs  which  are  still  called 
miracle  are  in  every  physician’s  handbag. 
There  are  good  reasons  to  believe  this  is  only 
the  beginning. 

A far  seeing  prophet  in  1910  could  have 
said  to  those  of  us  about  to  enter  practice, 
“Here  are  some  interesting  facts  that  to 
which  you  can  look  50  years  hence.” 

1.  You  will  not  have  seen  a clinical  case  of 
diphtheria  or  tetanus  for  several  years. 

2.  A suitable  formula  for  almost  all  babies 
can  be  purchased  in  a can  at  any  drugstore 
or  supermarket. 

3.  Typhoid  fever,  malaria,  and  pellagra 
will  be  text  book  diseases  that  you  will  rarely 
see,  if  ever. 

4.  It  will  be  at  least  ten  years  since  you 
have  seen  a case  of  surgical  mastoiditis. 

5.  Most  cases  of  pneumonia,  scarlet  fever, 
and  other  disease  will  be  treated  in  your  of- 
fice and  be  essentially  cured  within  24  hours. 

6.  Surgical  operations  within  the  heart 
will  be  common-place.  Repairs  and  correc- 
tion.s  on  valves  of  the  heart  will  frequently 
be  done.  Sections  of  the  large  blood  vessels 
near  the  heart  will  be  readily  replaceable. 

7.  Operative  procedures  within  the  crani- 
um will  be  in  use  for  cerebral  accidents  and 
other  conditions  formerly  thought  to  be  in- 
operable. 

All  science  of  which  medicine  is  a major 
segment  is  like  the  many  headed  hydra  of 
mythology.  Each  time  one  problem  is  solved 
two  new  ones  arise  to  take  its  place.  Each 
discovery  while  solving  some  old  question 
broadens  our  viewpoint  so  that  we  constantly 
see  new  and  more  complex  questions.  The 
more  progress  we  make,  the  more  is  seen  thatj 
we  do  not  understand. 


Changes  in  Medical  Education 

There  have  been  profound  changes  in  medi- 
cal education  during  the  past  half  century. 
In  1910  there  were  slightly  more  than  21,000 
medical  students  in  the  154  medical  schools 
then  in  the  United  States.  That  year  there 
were  4,436  medical  graduates  from  these 
schools.  Ten  schools  gave  only  the  first  two 
years  of  the  medical  curriculum.  Medical 
graduates  in  1959  numbered  6,869.  The  num- 
ber of  first  year  medical  students  in  1959  was 
8,128,  the  largest  number  to  date  in  the 
United  States.  For  1960  it  is  expected  that 
there  will  be  approximately  7,000  medical 
graduates  from  the  85  medical  schools  now  in 
the  United  States. 

The  studies  by  Abraham  Flexner  made  un- 
der the  auspices  of  the  Carnegie  Foundation, 
which  were  begun  in  1908  and  completed  in 
1910,  resulted  in  what  is  now  usually  referred 
to  as  the  Flexner  Report.  These  studies  laid 
the  foundation  for  improving  medical  edu- 
cation and  decreasing  the  large  number  of 
medical  schools  existing  fifty  years  ago. 

Medical  schools  in  the  United  States  and 
Canada  today  are  adequately  equipped  and 
have  competent,  well  qualified  faculties. 
Many  of  the  medical  schools  of  fifty  years 
ago  were  proprietary  and  served  the  personal 
interests  of  different  groups  of  practitioners 
who  owned  and  operated  them.  Only  slight- 
ly more  than  twenty  medical  schools  at  that 
time  required  two  or  more  years  of  college 
work  for  entrance. 

There  were  two  medical  schools  in  Ala- 
bama in  1910,  the  School  of  Medicine  of  the 
University  of  Alabama  at  Mobile,  and  Bir- 
mingham Medical  College  at  Birmingham. 
The  school  at  Mobile  was  organized  in  1859 
and  graduated  the  first  class  in  1861.  There 
were  subsequent  graduating  classes  for  all 
years  except  1862-1868  inclusive.  The  origi- 
nal name  was  the  Medical  College  of  Ala- 
bama. The  institution  was  reorganized  in 
1897  as  the  Medical  Department  of  the  Uni- 
versity of  Alabama  and  the  property  trans- 
ferred to  the  University  at  Tuscaloosa.  In 


74 


J.  M.  A.  ALABAMA 


FIFTY  YEARS  OF  MEDICINE 


1909  the  school  was  designated  as  the  School 
of  Medicine  of  the  University  of  Alabama. 

Birmingham  Medical  College  was  char- 
tered in  1894.  The  first  class  was  graduated 
in  1895.  This  school  was  amalgamated  with 
the  University  of  Alabama  in  1913  and  then 
was  discontinued  as  an  active  teaching  unit. 
There  were  179  medical  students  at  Mobile  in 
1910;  the  number  graduated  was  forty-one. 
For  the  same  year  at  Birmingham  there  were 
208  students,  including  one  woman,  and 
twenty  graduated.  This  gives  a total  of  387 
students  and  sixty-one  graduates  for  the  state 
for  that  year.  The  faculty  at  Mobile  con- 
sisted of  eight  professors  and  seventeen  lec- 
turers and  assistants,  a total  of  twenty-five, 
none  of  whom  were  full  time.  The  Birming- 
ham faculty  consisted  of  twenty-two  profes- 
sors and  twelve  assistants,  a total  of  thirty- 
four,  none  of  whom  were  full  time.  The  Mo- 
bile school  was  transferred  to  the  campus  of 
the  University  of  Alabama  at  Tuscaloosa  in 
the  fall  of  1920.  There  the  first  two  years 
of  the  medical  course  was  conducted  until 
June  1945  when  the  new  four  year  medical, 
dental,  and  nursing  schools  were  opened  as 
the  University  Medical  Center  at  Birming- 
ham, an  integral  unit  of  the  University  of 
Alabama. 

In  1960  at  the  Medical  College  of  Alabama 
in  Birmingham  there  are  300  medical  students 
including  29  women.  Of  these,  there  are  72 
in  the  fourth  year.  There  are  188  dental  stu- 
dents, 43  of  these  will  receive  their  degree 
in  dentistry  this  year.  There  are  also  165 
students  of  nursing  in  the  School  of  Nursing 
which  is  an  important  part  of  the  University 
Medical  Center.  Students  of  nursing  have 
the  option  of  receiving  a diploma  upon  com- 
pletion of  three  years  of  work  or,  if  they 
wish  a bachelors  degree  in  nursing,  they  can 
attain  that  upon  completion  of  the  prescribed 
course  of  four  years  of  study.  The  total  num- 
ber of  the  full  time  teaching  staff  of  the 
Medical  School  is  96.  There  are  332  part  time 
and  voluntary  teaching  staff  members,  ex- 
cluding dental  clinical  instructors. 


All  applicants  for  admission  to  the  Medical 
College  of  Alabama  now  must  have  at  least 
three  years-  of  college  work.  Of  the  300  medi- 
cal students  enrolled  in  the  Medical  College 
in  1960,  254  have  a bachelor’s  or  higher  de- 
gree. 

Each  generation  of  medical  students  de- 
velops in  a different  world  as  it  were.  Medi- 
cal science  has  made  tremendous  advances 
even  for  those  who  have  been  out  of  medical 
school  only  a decade  or  two.  To  each  suc- 
cessive generation  that  goes  through  our 
medical  schools  the  same  general  principles 
of  change  and  progress  will  continue  to  apply. 
One  of  the  changes  that  has  taken  place  in 
medical  education  within  recent  years  has 
been  in  the  students  themselves.  They  are 
somewhat  older,  more  serious  minded  and 
are  constantly  pressing  forward  toward  their 
goal.  The  number  of  married  students  in 
medicine  has  been  one  of  the  notable  changes 
during  the  past  twelve  or  fifteen  years.  From 
three  to  sixteen  per  cent  of  first  year  stu- 
dents are  now  married  when  they  enter  medi- 
cal school.  Not  infrequently  the  wife  of  a 
married  student  makes  an  important  finan- 
cial contribution  to  the  family  maintenance 
during  the  medical  school  and  interne  or  resi- 
dency period.  As  a class  progresses  through 
the  four  years  of  the  medical  course,  there 
is  each  year  a larger  percentage  of  married 
students,  until  by  the  time  the  fourth  year  is 
reached  as  many  as  75  or  80  per  cent  of  the 
class  may  be  married.  Fifty  years  ago, 
hardly  more  than  one  or  two  men  in  each 
class  were  married. 

These  changes  are  mentioned  not  to  decry 
them  but  to  call  attention  to  them  and  to 
say  that  personal  observation  of  the  present 
generation  of  medical  students  indicates  that 
they  are  earnest,  hardworking  individuals 
who  are  preparing  themselves  with  care  for 
their  career  in  medicine.  The  wives  who 
vicariously  go  through  the  course  with  their 
husbands  have  an  insight  and  understanding 
of  the  various  facets  of  medicine  that  will  be 
helpful  to  both  the  physician  and  his  wife 
when  they  settle  down  in  some  phase  of  medi- 
cal activity. 


AUGUST  I960— VOL.  30,  NO.  2 


75 


FIFTY  YEARS  OF  MEDICINE 


The  Viiturc 

Since  the  early  mists  of  antiquity,  man  has 
been  trying  to  look  into  the  future.  Today  as 
heretofore,  the  future  is  a most  intriguing 
subject  for  discussion. 

Without  attempting  to  assume  the  role  of 
a prophet,  but  looking  forward  to  fifty  years 
hence,  perhaps  we  could  say  that  during  that 
period  the  coming  generation  of  physicians 
will  see  the  following  transpire: 

1.  Cancer  and  leukemia  will  have  been 
relegated  to  medical  history. 

2.  The  common  cold  will  have  been  for- 
gotten. 

3.  Babies  will  rarely  be  born  prematurely. 

4.  A simple  explanation  and  method  of 
control  will  have  been  found  for  allergy. 

5.  A single  injection  or  pill  will  immunize 
children  against  all  of  the  communicable  dis- 
eases. 

6.  Many  congenital  defects  will  be  pre- 
vented by  advances  in  the  knowledge  of 
genetics. 

7.  Diseases  such  as  diabetes,  arthritis,  and 
cystic  fibrosis  will  easily  be  controlled  by  in- 
creased knowledge  of  the  enzyme  system. 

8.  Surgical  procedures  will  continue  to  be 
improved  particularly  within  the  cranial, 
thoracic,  and  abdominal  cavities. 

9.  Replacement  of  parts  of  the  body  will 
progress  beyond  anything  within  our  pres- 
ent imagination. 

10.  The  atomic  energy  and  radio  active 
fields  will  add  much  to  the  accuracy  of  diag- 
nostic and  treatment  procedures. 

11.  Mental  disease  that  now  fills  half  of 
the  hospital  beds  in  our  nation  will  be  great- 
ly reduced  by  new  preventive,  diagnostic  and 
treatment  methods. 

Even  with  these  diseases  and  conditions 
under  control,  there  will  be  many  things  re- 
maining to  challenge  and  stimulate  the  phy- 
sician in  the  year  2010.  The  problems  of  dis- 
posal of  the  waste  products  from  the  produc- 


tion of  atomic  energy  looms  as  a matter  of 
much  concern.  Space  travel  and  exploration, 
the  problems  of  a rapidly  increasing  popula- 
tion throughout  the  world  may  be  current 
subjects  for  discussion  at  the  fiftieth  anni- 
versary of  the  medical  class  of  1960. 

As  loyal  sons  of  our  Alma  Mater  may  we 
present  some  suggestions  for  consideration 
by  our  school  and  our  medical  graduates 
during  the  next  fifty  years.  The  continuing 
strength  of  any  medical  school  rests  upon  its 
faculty,  students,  and  alumni.  Any  educa- 
tional institution  maintains  a lifelong  asso- 
ciation with  its  alumni  which  ends  only  with 
the  death  of  the  individual.  Students  come 
and  go,  and  after  completing  their  training 
join  us  as  alumni.  As  each  class  of  students 
matures  to  graduation,  they  maintain  the 
continuity  which  perpetuates  our  alumni  as- 
sociation through  new  members  and  in- 
creased strength  in  numbers.  Our  alumni 
are  the  stockholders  with  the  school  in  our 
common  enterprise  of  preparing  persons  for 
the  medical  profession  and  sustaining  high 
standards  of  professional  work  and  conduct. 
They  are  the  mark  of  our  accomplishments. 

As  alumni,  if  our  school  gains  renown  and 
a favorable  reputation  some  of  it  rubs  off  on 
us.  If  any  of  our  alumni  attain  prominence, 
the  school  basks  in  their  reflected  glory.  We 
as  alumni  have  an  important  stake  in  the 
Medical  College  of  Alabama.  We  follow  its 
progress  with  pride;  we  serve  as  its  ambassa- 
dors wherever  we  go.  We  have  it  within 
our  power  to  contribute  something  of  im- 
portance to  the  leadership  and  service  of  our 
Alma  Mater. 

Our  school  is  also  a keeper  of  a trust  for  us. 
We  in  turn  must  never  give  her  cause  for 
regret.  This  is  the  ideal  relationship  which 
the  college  and  the  alumni  should  strive  to 
achieve  and  retain.  As  alumni  with  lofty 
ideals  and  a strong  affection  for  the  profes- 
sion of  medicine  let  us  ever  work  together 
toward  that  objective. 

The  man  who  day  by  day  barters  himself 
for  something  greater  than  himself  is  one  who 


76 


J.  M.  A.  ALABAMA 


FIFTY  YEARS  OF  MEDICINE 


merits  respect  and  appreciation.  In  a real 
sense,  physicians  in  their  daily  service  to 
mankind  barter  themselves  for  the  persons 
and  communities  whom  they  serve.  The 
care  a physician  thus  provides  his  patients 
is  for  the  preservation  and  restoration  of  the 
health  of  those  patients  as  well  as  the  pro- 
tection of  the  health  of  the  community.  These 


are  the  ends  toward  which  we  must  continu- 
ously direct  ourselves  as  physicians. 

REFERENCES 

1.  Cole,  Wyman  C.  C.:  Pediatrics  in  the  Space 
Age,  J.  A.  M.  A.  171:  641,  1959. 

2.  U.  S.  Public  Health  and  Marine  Hospital  Ser- 
vice, Annual  Report  1906,  page  53,  Yellow  Fever, 
United  States. 


AUGUST  I960— VOL.  30,  NO.  2 


77 


Sditormls 


Proposal  To  Strangle  Medical 
Research  With  Red  Tape 


ROBERT  C.  BERSON,  M.  D. 
Birmingham,  Alabama 


There  was  recently  introduced  into  the 
Senate  by  Senator  John  Sherman  Cooper  and 
ten  other  senators  a bill  to  “regulate”  the  use 
of  experimental  animals  by  institutions  re- 
ceiving federal  grants  or  working  on  federal 
contracts.  This  bill  (S.  3570)  would  license 
every  individual  scientist  who  might  work 
with  animals  under  any  federal  grant  or  con- 
tract. It  actually  proposes  to  create  a “cops 
and  robbers”  game  that  would  drain  away 
the  time  of  scientists  who  are  trying  to  find 
better  ways  to  save  lives  and  alleviate  suffer- 
ing. Laboratories  in  which  animal  research 
is  conducted  would  be  inspected  and  issued 
“certificates  of  compliance.”  Research  plans 
would  have  to  be  submitted  to  the  Secretary 
of  Health,  Education  and  Welfare  for  approv- 
al, and  presumably  no  variations  would  be 
permitted;  and  detailed  annual  reports  would 
have  to  be  made  on  each  licensee  covering  all 
experiments  performed  during  the  year. 

This  bill  actually  has  no  constructive  pro- 
vision. It  makes  no  provision  for  helping 
scientists  obtain  better  methods,  better  help- 
ers, or  better  facilities.  Good  care  of  labora- 
tory animals  is  more  than  a matter  of  hu- 
manity; it  is  also  a matter  of  scientific  ac- 
curacy and  efficiency.  No  pet  owner  spends 
as  much  for  special  diets,  medicines,  equip- 
ment, and  professional  care  as  is  spent  on  test 
animals  because  a stray  germ  or  an  unantici- 


pated physical  condition  in  a test  animal  can 
waste  all  of  the  work  put  into  the  piece  of 
research. 

Laboratory  animal  care  is,  like  all  fields  of 
human  activity,  capable  of  infinite  progress; 
but  the  progress  is  down  four  lines:  research 
in  laboratory  animal  husbandry,  training  in 
laboratory  animal  husbandry,  rapid  dissemi- 
nation of  new  knowledge  on  animal  care  tech- 
niques, and  better  animal  research  facilities. 

In  our  own  state  of  Alabama,  both  at  the 
Medical  College  and  at  the  Southern  Re- 
search Institute,  great  progress  has  been 
made  in  providing  adequate  animal  facilities 
and  competent  supervision,  proper  diet, 
health,  and  comfort  of  all  of  the  animals  used 
in  scientific  research.  These  measures  are  ex- 
pensive, and  considerable  effort  as  well  as 
the  cooperation  of  many  people  have  gone  in- 
to acquiring  facilities  and  resources  to  pro- 
vide adequate  care  for  laboratory  animals. 
It  is  to  be  hoped  that  there  will  be  thorough 
hearings  on  the  Cooper  Bill  because  such 
hearings  would  lead  Congress  to  a better  un- 
derstanding of  the  complex  subject  of  labo- 
ratory animal  care,  and  this  might  result  in  a 
plan  to  help  scientists  get  the  better  facili- 
ties and  the  latest  information  on  animal  care 
that  can  mean  so  much  to  their  work  as  well 
as  to  the  comfort  and  welfare  of  the  animals. 


78 


J.  M.  A.  ALABAMA 


EDITORIAL  SECTION 


Social  Effects  Of  Pep  Pills 
Can  Be  Good  And  Bad 

Amphetamine,  a commonly  used  stimulant, 
can  have  both  a good  and  a bad  effect  on  an 
individual’s  social  behavior,  a study  indicated 
recently. 

The  conclusion  was  based  on  a study  in- 
volving athletes  given  the  so-called  “pep 
pills”  and  asked  to  describe  how  they  felt 
before  and  after  by  filling  out  an  81-item 
check  list. 

Writing  in  the  April  issue  of  the  Journal  of 
the  American  Medical  Association,  G.  M. 
Smith,  PH.D.,  and  Henry  K.  Beecher,  M.D., 
of  the  Harvard  Medical  School,  said  there 
has  been  considerable  interest  in  the  question 
of  whether  amphetamine  produces  tempo- 
rary alterations  in  personality  which  might 
facilitate  antisocial  behavior. 

The  authors  referred  to  reports  that  law- 
breakers take  “thrill  pills”  to  bolster  their 
courage  to  commit  crimes  and  pointed  out 
that  the  same  type  of  pills  are  believed  to  be 
in  widespread  use  by  students,  businessmen, 
and  other  non-criminal  citizens. 

In  the  present  investigation,  they  said,  in- 
creased feelings  of  mental  and  physical  ac- 
tivation, elations,  boldness,  and  friendliness 
were  the  main  effects  of  amphetamine  on 
mood  and  physical  states. 

The  increase  in  effects  classified  as  bold- 
ness and  friendliness  is  pertinent  to  the  issue 
of  antisocial  behavior;  perhaps  the  increased 
checking  of  drunk  and  impulsive  is  also,  since 
increases  in  these  two  effects  may  imply  a 
reduction  in  self-control. 

The  athletes  checked  the  “bold,  boastful, 
cocky,  self-confident,  playful,  and  domineer- 
ing” categories  more  and  the  “insecure” 
category  less  when  under  the  influence  of 
amphetamine,  the  researchers  said. 

Those  mood  changes  might,  under  certain 
circumstances,  facilitate  antisocial  behavior, 
particularly  the  changes  in  feelings  which  ac- 

AUGUST  I960— VOL.  30,  NO.  2 


count  for  the  increased  checking  of  cocky  and 
domineering,  they  said. 

However,  the  increased  boldness  was  ac- 
companied by  greater  friendliness,  as  indi- 
cated by  more  checking  of  friendly,  talkative, 
goodnatured,  obliging,  and  trustful  and  less 
checking  of  grouchy,  unsocial,  and  sarcastic. 

The  consequences  of  simultaneously  in- 
creasing friendliness  and  boldness  are  not 
known,  they  said.  Furthermore,  they  said, 
it  is  almost  certain  that  such  behavior  con- 
sequences would  be  strongly  influenced  by 
social  and  environmental  circumstances. 

The  data  of  the  present  investigation  indi- 
cate that  most  nondelinquent  persons  who 
take  amphetamine  in  a moderate  dose,  such 
as  that  used  in  the  present  study,  and  who  do 
so  in  a situation  in  which  social  forces  tend 
to  inhibit  rather  than  promote  antisocial  be- 
havior are  likely  to  experience  mood  effects 
which  contain  both  socially  positive  and  so- 
cially negative  elements,  they  concluded. 

An  earlier  report  by  the  same  authors 
showed  that  average  doses  of  amphetamine 
improved  athletes’  performances. 

Both  men  are  associated  with  the  Anes- 
thesia Laboratory  of  the  Harvard  Medical 
School  at  the  Massachusetts  General  Hospital, 
Boston. 

Clinical  Re-Evalua+ion 
Of  Daytime  Sedatives 

This  investigation  was  made  to  determine 
which  representative  agents  currently  used 
for  controlling  anxiety  states  most  nearly 
meet  the  specifications  outlined  for  an  ideal 
sedative. 

To  conform  with  conditions  encountered  in 
everyday  general  practice,  response  was  rat- 
ed according  to  rigid  “all  or  none”  criteria 
of  efficacy.  Anything  less  than  complete  re- 
lief was  regarded  as  a failure. 

Because  insomnia  accompanied  daytime 
anxiety  in  about  70  per  cent  of  the  patients 

79 


EDITORIAL  SECTION 


treated,  the  authors  observed  the  effective- 
ness of  small  multiple  daytime  doses  of  each 
drug  in  controlling  both  symptoms.  They 
also  considered  the  response  in  terms  of  a 
“therapeutic  index” — per  cent  effectiveness; 
per  cent  untoward  reactions. 

One  hundred  sixty-eight  ambulatory  out- 
patients with  clearly  defined  symptoms  of 
anxiety  and  nervous  tension  were  studied 
during  a five-year  period. 

Six  widely  used  sedatives  or  tranquilizers 
and  a placebo  were  studied  in  357  trials — 15 
and  30  mg.  phenobarbital,  15  and  30  mg.  doses 
of  butabarbital  sodium,  200  mg.  acetylcar- 
bromal,  125  and  250  mg.  glutethimide,  400  mg. 
meprobamate  and  5 mg.  prochlorperazine. 

Trials  were  continued  uninterrupted  for 
not  less  than  two  weeks  and  usually  for  three 
weeks  or  longer. 

Multiple  comparative  trials  were  made  in 
over  half  the  patients. 

Butabarbital  sodium  provided  the  highest 
rating  (therapeutic  index)  reflecting  clinical 
usefulness  of  sedatives  studied  for  control  of 
anxiety  states  as  compared  with  side  effects. 
Butabarbital  sodium  was  also  the  only  drug 
that  gave  satisfactory  control  of  both  day- 
time and  nighttime  symptoms  of  anxiety 
without  recourse  to  additional  therapy. 

Glutethimide  in  small  doses  is  an  effective 
daytime  sedative,  but  supplementary  hynotic 
doses  are  required  to  control  insomnia. 

Phenobarbital  and  acetylcarbromal  pro- 
duce satisfactory  daytime  sedation,  but 
chronic  administration  produces  a high  in- 
cidence of  cumulative  toxicity.  Meprobamate 
and  prochlorperazine,  representative  atarac- 
tic drugs,  were  not  found  satisfactory  day- 
time sedatives. 

Aspirin  Does  Not  Cause 
Ulcer  Or  Anemia 

A six-year  study  of  patients  with  rheuma- 
toid arthritis  concludes  that  reports  that  as- 
pirin causes  gastrointestinal  bleeding,  peptic 
ulcers,  or  anemia  “have  been  greatly  exag- 
gerated.” 


The  study  is  believed  to  be  the  most  au- 
thoritative made  on  the  subject,  from  the 
standpoint  of  the  number  of  patients  and  the 
length  of  time  under  observation.  The  proj- 
ect was  directed  by  Dr.  F.  D.  Baragar  and  J. 
J.  R.  Duthie  of  the  Rheumatic  Diseases  Unit, 
Northern  General  Hospital,  Edinburgh,  Scot- 
land. It  is  described  in  the  April  issue  of  the 
British  Medical  Journal. 

The  investigators  studied  244  victims  of 
rheumatoid  arthritis  for  a period  of  six 
years,  the  great  majority  of  whom  were  tak- 
ing aspirin  regularly.  It  was  found  that  the 
group  showed  a significant  increase  in  hemo- 
globin level  over  the  period  of  the  study. 
The  hemoglobin  level  would  have  dropped  if 
the  aspirin  had  caused  anemia  or  ulcer. 

“Further  evidence  against  the  idea  that  sa- 
licylates are  an  important  cause  of  anemia  i3 
provided  by  comparing  the  progress  of  a 
small  group  of  patients  who  were  not  taking 
regular  aspirin  with  another  small  group  who 
were  taking  regular  and  adequate  doses  of 
the  drug. 

“The  group  not  requiring  aspirin  started 
with  a higher  hemoglobin  level  and  gained 
in  about  the  same  proportion  as  the  group  on 
regular  doses,”  the  authors  state. 

Only  three  of  the  244  patients  in  the  series 
developed  detectable  ulcers.  This  was  1.2  per 
cent  of  the  total,  and  below  the  incidence  of 
peptic  ulcer  in  the  general  population. 

“It  would  thus  appear  that,  even  if  the  ma- 
jority of  patients  with  unexplained  dyspep- 
sia are  accepted  as  also  having  ulcers,  there 
is  no  good  evidence  that  aspirin  causes  an  in- 
creased incidence  of  peptic  ulcer  in  patients 
with  rheumatoid  arthritis.” 

Reporting  to  the  British  Medical  Associa- 
tion on  the  results  of  their  study,  the  investi- 
gators conclude: 

“The  great  majority  of  patients  with  rheu- 
matoid arthritis  can  tolerate  regular  aspirin 
without  an  increase  in  anemia.  The  dangers 
of  causing  peptic  ulceration  or  precipitating 
gastrointestinal  hemorrhage  appear  to  have 
been  greatly  exaggerated.” 


80 


J.  M.  A.  ALABAMA 


THE  AGING  PROBLEM 


Governor  Patterson  is  to  be  commended  for 
his  keen  interest  in  the  problem  of  the  aging 
as  evidenced  by  the  State  Conference  on  Ag- 
ing held  in  Tuscaloosa  in  June  of  this  year. 
Over  five  hundred  persons  from  labor,  recre- 
ational, religious,  medical,  and  social  service 
groups  attended.  This  meeting  served  as  a 
nucleus  for  the  White  House  Conference  on 
Aging  which  is  to  be  held  in  Washington,  D. 
C.,  next  January.  Alabama  has  43  county 
committees  working  on  the  problem  at  pres- 
ent. 

Some  striking  facts  were  brought  out  at 
the  meeting.  There  are,  as  of  now,  approxi- 
mately fifteen  million  people  65  years  of  age 
or  older  in  this  country.  By  1970,  it  is  esti- 
mated that  this  number  will  be  over  twenty 
million. 

Whereas,  nationally,  80  per  cent  of  the 
aged  are  quoted  as  able  to  care  for  them- 
selves, 50  per  cent  in  Alabama  are  dependent. 
Twenty-two  per  cent  are  illiterate!  We  rank 
third  from  the  bottom  in  these  two  categories. 

Four  out  of  five  of  our  older  citizens, 
though  active,  are  afflicted  with  some  chron- 
ic disease  and,  workwise,  cannot  be  rehabili- 
tated. 

In  Alabama,  investigation  revealed  that  75 
per  cent  of  the  aged  spent  less  than  $100  per 


year  on  illness.  Forty  per  cent  received  old 
age  benefits  of  $53.21  per  month  while  30  per 
cent  received  social  security  payments  of  $61 
per  month. 

From  the  above  figures  and  facts,  these 
conclusions  can  be  made; 

1.  In  our  state,  there  has  been  and  there 
remains  a need  for  educational  facili- 
ties, specialized  training,  and  opportuni- 
ties for  advancement — also  jobs. 

2.  There  is  need  for  medical  care,  both  cor- 
rective and  preventive,  and  for  selective 
rehabilitation. 

3.  The  indigent  and  limited  income  groups 
need  assistance,  frequently  in-hospital 
and  nursing  home  care.  Included,  also, 
should  be  nursing  and  counselling  needs 
and  housing  facilities. 

4.  There  is  need  for  continued  study  of  the 
whole  problem  relating  to  the  aged. 


Hugh  Gray,  M.  D. 


AUGUST  I960— VOL.  30,  NO.  2 


81 


Transactions  Of  The  Annual  Meeting  Of 
The  Woman's  Auxiliary  To  The 
Medical  Association  Of  The  State  of  Alabama 


FIRST  GENERAL  SESSION 
Thursday,  April  21 

The  Woman’s  Auxiliary  to  the  Medical  As- 
sociation of  the  State  of  Alabama  convened  in 
annual  meeting  at  the  Battle  House  Hotel  in 
Mobile  on  April  21,  1960,  and  was  called  to 
order  at  10  a.  m.  by  the  president,  Mrs. 
George  W.  Newburn,  Jr. 

Following  the  invocation  and  the  member- 
ship pledge,  Mrs.  Newburn  welcomed  those 
in  attendance  and  introduced  guests. 

Mrs.  B.  B.  Kimbrough  read  the  convention 
rules  of  order.  Mrs.  Frank  England  gave  the 
report  of  the  Credentials  Committee,  and  the 
report  of  the  Reading  Committee  was  given 
by  Mrs.  Joe  Cromeans. 

REPORTS  OF  OFFICERS 

Preshlcnf 

Mrs.  George  W.  hleivbnru,  Jr. 

This  past  year  has  been  a wonderful  experience. 
When  I assumed  the  privileged  responsibility  of 
the  presidency  of  the  Woman’s  Auxiliary  to  the 
Medical  Association  of  the  State  of  Alabama,  I did 
so  with  many  misgivings.  I truly  felt  very  inade- 
quate for  the  job.  Auxiliary  work  has  long  been 
a love  of  mine;  and  as  the  year  began  last  April, 
I found  I had  much  to  learn,  many  plans  to  make, 
hundreds  of  letters  to  write,  and  traveling  to  do 


by  train,  car,  and  plane.  But  best  of  all  were  the 
new  friends  to  be  found  all  over  the  50  states  and, 
last  but  not  least,  just  getting  to  know  you  better. 

I was  proud  to  represent  you  and  give  Sylvia 
Rosen’s  yearly  report  at  the  36th  annual  conven- 
tion of  the  Woman’s  Auxiliary  to  the  American 
Medical  Association  in  Atlantic  City. 

Returning  home,  I stopped  in  Montgomery  to 
attend  the  Public  Relations  Committee  meeting  of 
the  State  Medical  Association.  Out  of  this  meet- 
ing came  our  essay  contest;  but  for  fear  of  steal- 
ing someone  else’s  thunder,  that’s  all  I will  say 
about  the  contest. 

During  the  summer,  plans  were  made  for  our 
fall  board  meeting  to  be  held  in  Montgomery  in 
September.  Those  of  you  who  attended  remember 
the  fun  we  had  getting  “Information  Please”  from 
each  other. 

In  October  I was  in  Chicago  at  the  National  Con- 
ference for  Presidents  and  Presidents-Elect.  That 
is  the  meeting  where  they  indoctrinate  you.  They 
set  you  on  fire  with  all  the  worthwhile  projects  of 
our  Auxiliary. 

In  November  I was  in  Atlanta  for  the  Southern 
Medical  Association  meeting.  Our  own  Belle 
Chenault  was  installed  as  President. 

After  the  first  of  the  year,  I had  the  pleasure  of 
visiting  many  of  our  thirty-one  organized  counties 
— back  to  the  grass  roots  and  to  the  girls  who  make 
up  the  Auxiliary.  Let  me  say  here,  “Thank  you 
for  the  work  you  have  done  this  year.”  No  wonder 
I was  proud  to  represent  you  at  the  various  meet- 
ings! 

In  March  I represented  you  at  the  Southern  Re- 
gional Conference  on  Aging  in  Atlanta.  The  next 
week  I was  in  Montgomery  at  the  Cancer  Society 
meeting.  Since  I could  not  divide  myself  in  two, 
it  was  impossible  to  attend  the  National  Founda- 


02 


J.  M.  A.  ALABAMA 


ORGANIZATION  SECTION 


tion  meeting  in  Montgomery  or  the  Civil  Defense 
meeting  in  Birmingham.  I was  ably  represented 
at  the  latter  by  Mrs.  E.  V.  Caldwell,  our  Civil  De- 
fense chairman. 

Today,  you  will  hear  from  the  county  presidents; 
then  you  will  know  that  each  member  has  accepted 
“Individual  Responsibility  for  Better  Community 
Health”  as  a real  challenge  to  participate  in  worth- 
while community  activities. 

In  reviewing  the  year,  I see  the  same  old  gaps 
in  our  structure.  We  still  do  not  have  every  phy- 
sician’s wife  as  a member.  Counties  that  should 
organize  have  not  done  so.  Some  of  us  take  our 
membership  too  lightly.  I would  recommend  that 
you  invite  the  physician’s  wife  who  is  not  a mem- 
ber to  become  one  and  see  that  she  joins  and  is 
informed  about  our  Auxiliary  work.  Then  to  you 
members  at  large,  go  back  home  and  see  if  there 
is  not  just  the  possibility  of  organizing. 

I cannot  close  this  report  without  saying  to  each 
officer,  chairman,  and  member  a sincere  “thank 
you”  for  your  gracious  giving  of  yourself  to  fur- 
ther our  Auxiliary  work  and  making  this  year  one 
to  be  cherished  by  me.  I hope  I have  been  worthy 
of  the  trust  you  placed  in  me.  Thank  you. 

T r casin' cr 

Mrs.  Chester  K.  Beck 

Financial  Statement 

July  1,  1959  to  April  1,  1960 

Receipts: 


Balance  on  Hand _ . . $1,637.20 

Dues  Collected  County  Auxiliaries  _ 3,756.00 

Alabama  Medical  Association  for 

Newsletter  200.00 

Handbooks  (seven)  from 
Mrs.  John  Chenault  3.50 

$5,596.70 


Disbursements: 

National  Dues  to  Mrs.  Harlan  English  1,252.00 


(1252  members) 

Expenses  of  Officers: 

Mrs.  George  Newburn,  Jr.  (National 
Conference,  travel  to  counties, 
stationery,  postage,  supplies. 

National  Convention)  _ 728.08 

Mrs.  George  Newburn,  Jr. — Down 

Payment  on  Yearbooks 50.00 

Mrs.  Sylvia  Morris,  National  Con- 
ference, Expenses — as  President- 

Elect  . 170.00 

Mrs.  Chester  K.  Beck,  Expenses 

as  Treasurer  25.00 

Mrs.  S.  J.  Walker,  Expenses  as 

Corresponding  Secretary 10.00 


Expenses  of  Chairmen: 

Mrs.  William  Noble  (Nominating 

Committee — 1959)  34.78 

Mrs.  Seaburt  Goodman  (A.M.E.F.)  . 20.00 

Mrs.  William  Brock  (Newsletter)  3.00 

Mrs.  J.  C.  Chambliss  (Nominating 

Committee — 1960)  ..  . . . . 21.29 

Mrs.  W.  L.  Smith,  Luncheon  Ticket 

Board  Meeting  (L.  H.  Clemmons)  2.50 

Mrs.  Frank  Fain  (S.A.M.A.)  150.00 

Harbin  Office  Equipment — 

(Filing  Cabinet)  . . 41.60 

Toulminville  Printing  Company 

(Yearbooks)  . 

Stationery  . 236.56 

Davis  Printing  Company 

(Newsletter)  ...  375.54 

Claude  Moore  Jeweler  (Prizes  for 

Exhibits)  43.16 

Joint  Legislative  Council  Dues  ..  15.00 

Honorary  Member  (Mrs.  E.  F. 

Leatherwood)  . 3.00 

Bromberg  (Past  President’s  Pins)  ..  58.17 

Alabama  Medical  Association  for 
Mimeographing,  and  Stationery..  16.41 

Total  Disbursements  . $3,256.09 

TOTAL  RECEIPTS  5,596.70 

Total  Disbursements  . 3,256.09 

Bank  Balance  April  11th  $2,340.61 


REPORTS  OF  STATE  CHAIRMEN 


Membership 

As  of  the  beginning  of  this  meeting,  there  are 
1,261  paid  members  of  the  State  Auxiliary.  During 
the  past  year  15  of  the  31  county  Auxiliaries  have 
increased  in  membership.  Five  remained  the 
same,  and  nine  showed  a reduction.  There  are  51 
members-at-large  in  counties  where  there  are  no 
organized  Auxiliaries. 

Aimrican  Medical  Education  Foundation 

During  1959  contributions  given  through  the 
Auxiliary  to  A.  M.  E.  F.  totaled  $4,643.40.  This 
was  an  increase  by  63  per  cent  over  the  preceding 
year’s  contribution. 

Ciiil  Defense 

During  the  past  year,  16  Auxiliaries  cooperated 
with  the  local  Civil  Defense  organizations;  and  12 
had  Civil  Defense  programs.  During  the  year, 
65  members  took  home  nursing  courses;  and  13 
members  served  as  teachers  in  home  nursing. 
First  Aid  courses  were  attended  by  102  members, 
and  20  served  as  teachers.  Fifty-five  members 
have  prepared  their  homes  for  a disaster,  while 
fifteen  members  participated  in  other  Civil  De- 
fense activities. 


AUGUST  I960— VOL.  30,  NO.  2 


83 


ORGANIZATION  SECTION 


Reports  of  County  Presidents 

The  following  county  Auxiliaries  were  repre- 
sented, and  each  representative  gave  a two  min- 
ute summary  of  the  County  Auxiliary  program 
during  the  past  year:  Blount,  Jackson,  Madison, 

Jefferson-Birmingham,  Marion,  Pickens,  Coffee, 
Covington,  Elmore,  Montgomery,  Pike,  Clarke, 
Conecuh-Monroe,  Dallas,  and  Mobile. 

Memorial  Service 

Mrs.  G.  G.  Woodruff  led  the  Memorial  Service 
for  those  members  who  had  deceased  during  the 
past  year.  They  were  Mrs.  E.  W.  Couch,  Mrs.  R. 
A.  Culpepper,  Mrs.  John  England,  Mrs.  James  E. 
Middleton,  Mrs.  Berney  Moore,  Jr.,  Mrs.  C.  W. 
Ramey,  Mrs.  N.  E.  Sellers,  and  Mrs.  George  Waller. 


Luncheon , Skyline  Country  Club 

Mrs.  John  M.  Chenault,  President  Woman’s 
Auxiliary  to  the  Southern  Medical  Associa- 
tion, made  the  address  following  the  lunch- 
eon. 

Mrs.  Chenault  stated  that  the  Auxiliary  to 
the  Southern  Medical  Association  has  three 
main  projects:  To  promote  fellowship;  spon- 
sor Doctor’s  Day  on  a local  level;  and  collect 
and  preserve  historical  papers,  lectures,  and 
histories  of  the  early  physicians.  This  latter 
project,  she  pointed  out,  is  called  “Research 
and  Romance  of  Medicine”;  and  the  papers 
are  kept  in  the  Southern  Medical  Association 
headquarters  building  in  Birmingham. 

Mrs.  Chenault  then  reminisced  for  a while 
on  the  humorous  aspects  of  some  of  the  con- 
ventions which  she  had  attended. 

An  invitation  was  extended  by  Mrs.  Che- 
nault to  the  members  to  attend  the  Annual 
Convention  of  the  Auxiliary  to  the  Southern 
Medical  Association  when  it  meets  in  St. 
Louis  in  the  fall.  She  also  urged  the  Auxil- 
iary members  to  make  use  of  the  Research 
and  Romance  Library  in  Birmingham  and 
stated  that  the  Southern  Auxiliary  maintains 
this  as  a special  service  for  students  and  any- 
one in  the  medical  field. 

Following  Mrs.  Chenault’s  speech  the  la- 
dies were  entertained  with  an  accessory  style 
show  which  was  staged  by  Hammel’s. 


SECOND  GENERAL  SESSION 
Friday,  April  22 

The  first  order  of  business  was  the  consid- 
eration of  proposals  discussed  at  the  pre-con- 
vention Executive  Board  meeting.  The  fol- 
lowing recommendations  from  the  Executive 
Board  were  approved; 

1.  That  a notice  be  placed  in  the  newslet- 
ter to  members  of  unorganized  counties  to 
the  effect  that  those  members  should  present 
their  husbands  with  red  carnations  on  Doc- 
tor’s Day. 

2.  That  the  last  year’s  entire  and  final  re- 
ports be  considered  and  kept  in  mind  by  the 
incoming  Board. 

3.  That  consideration  be  given  to  selecting 
an  elderly  member  as  the  next  recruitment 
chairman. 

4.  That  the  Auxiliary  contribute  the  sum 
of  $100  to  A.M.E.F. 

5.  That  the  Auxiliary  continue  support  of 
the  Essay  Contest  providing  such  support  be 
requested. 

6.  That  the  Auxiliary  give  the  sum  of  $10 
allotted  to  Today’s  Health  to  Public  Relations 
and/or  Community  Service,  thus  making  a 
total  allotment  to  Public  Relations  and/or 
Community  Service  of  $20. 

7.  That  this  Auxiliary  send  the  name  of 
Mrs.  William  G.  Thuss  to  the  National  Nomi- 
nating Committee. 

The  proposed  budget  for  the  coming  year 
was  then  presented  to  the  membership. 

I’roposetl  Budget  for  1960-1961 

Income 

Dues  (Estimated  1252  members) $2,504.00 

Expenditures 

Travel 

National  Convention, 

Pres.  ..  . $300.00 

National  Conference, 

Pres.  ..  . 150.00 

County  and  District 

Meetings,  Pres. ...  150.00 
National  Conference, 

Pres. -Elect  . 150.00 

Reserve:  West 

Coast  Convention  50.00  $800.00 


84 


J.  M.  A.  ALABAMA 


ORGANIZATION  SECTION 


President’s  Newsletter  25.00 

Yearbooks  250.00 

Stationery  and  Supplies 60.00 

Postage  45.00 

WAMASA  News  ...  225.00 

Newsletter  Chairman  10.00 

Board  Meeting 30.00 

Convention  ..  60.00 


Offices  of 

President-Elect 

$ 50.00 

Vice-Presidents 

(four)  ..  . 

50.00 

Treasurer 

25.00 

Auditor 

. 25.00 

Recording  Secretary  5.00 

Finance  Officer  .. 

5.00 

Historian  . . 

5.00 

Parliamentarian 

5.00 

Corresponding 

Secretary  

. 30.00 

Offices  of  Committee  Chairmen 
Members-at-Large  $ 15.00 
Public  Relations 


and/or  Communi- 


ty  Service 

20.00 

Civil  Defense 

5.00 

Mental  Health 

5.00 

Southern  Project 

5.00 

Bulletin 

5.00 

Lettie  Baffin 

Perdue  Fund 

5.00 

Safety 

5.00 

Memorial 

5.00 

Legislation 

5.00 

Recruitment 

50.00 

Archives  & Exhibits 

50.00 

Nominating  

30.00 

205.00 

Report  Forms  

60.00 

Past  President’s  Pin 

10.00 

Joint  Legislative  Council  Dues  15.00 

Honorary  Memberships 

6.00 

Special  Projects .. 

150.00 

W.  A.  S.  M.  A. . - 

150.00 

2,301.00 

Unencumbered  Miscellaneous  Fund 

. $ 203.00 

In  view  of  the  fact 

that 

the  program  for 

the  Mental  Health  Committee  had  not  been 


completed,  it  was  decided  that  in  the  event 
the  committee  chairman  for  Mental  Health 
should  require  an  additional  appropriation 
other  than  the  $5  set  forth  in  the  proposed 
budget,  such  additional  sum  shall  be  appro- 
priated out  of  any  surplus  fund  in  the  treas- 
ury. With  this  stipulation  the  proposed  bud- 
get was  adopted. 


Constitutional  Amendments 

Following  introduction  of  guests  and  an- 
nouncements by  the  President,  the  Revisions 
Committee  recommended  the  following 
changes  to  the  Constitution  of  the  Auxiliary. 
After  full  discussion  the  following  revised 
sections  of  the  Constitution  were  approved: 

ARTICLE  II— OBJECT 

The  objects  of  this  Auxiliary  shall  be: 

1.  To  assist  the  Medical  Association  of  the 
State  of  Alabama. 

2.  To  advance  the  cause  of  preventive  medi- 
cine. 

3.  To  secure  adequate  medical  legislation. 

4.  To  promote  good  fellowship  among  phy- 
sicians’ families. 

5.  To  assist  in  entertaining  the  state,  county 
and  district  conventions. 

6.  To  accomplish  supplemental  work  as  may 
be  suggested  by  the  Medical  Association. 

7.  To  administer  an  endowment  fund. 

ARTICLE  III— DUTIES  OF  OFFICERS 

Section  2 — The  President-Elect  shall  be  an  ex 
officio  member  of  the  Executive  Board.  She  shall 
act  as  Chairman  of  the  Committee  on  Membership. 
She  shall  familiarize  herself  with  all  phases  of 
Auxiliary  work  in  preparation  for  the  office  of 
President. 

Section  3 — Each  of  the  four  Vice-Presidents 
shall  be  responsible  for  membership  of  specific 
territory  assigned  to  her  by  the  Executive  Board. 
Each  shall  arrange  and  preside  over  an  annual  dis- 
trict meeting  and  in  so  doing,  promote  the  attend- 
ance of  new  organizations  and  members-at- 
large.  The  Vice-Presidents,  and  Chairman  of  the 
members-at-large,  with  the  President-Elect,  shall 
constitute  the  Committee  on  Membership.  Each 
of  the  Vice-Presidents  shall  serve  as  Editor  of 
WAMASA  News  in  her  respective  district;  she 
shall  encourage  County  Auxiliaries  and  members- 
at-large  to  send  in  items  of  interest  to  the  State 
Auxiliary  for  each  issue. 

ARTICLE  IV— EXECUTIVE  BOARD 

Section  1 — The  officers,  all  committee  chair- 
men, and  presidents  of  County  Auxiliaries  shall 
constitute  an  Executive  Board  of  which  the  Auxili- 
ary President  and  Secretaries  shall  be  respectively 
Chairman  and  Secretaries. 

(a)  By  reason  of  her  office,  a member  serving 
in  an  office  of  chairman  in  Woman’s  Auxili- 
ary to  the  American  Medical  Association 
shall  hold  membership  on  this  Board  and 
shall  have  voting  privilege. 

(b)  By  reason  of  her  office,  a member  serving 
as  an  officer  in  Woman’s  Auxiliary  to  the 
Southern  Medical  Association  shall  hold 


AUGUST  I960— VOL  30,  NO.  2 


85 


ORGANIZATION  SECTION 


membership  on  this  Board  and  shall  have 
voting  privilege. 

ARTICLE  V— OFFICERS  AND  METHODS  OF  ELECTING 

Section  2 — These  officers,  with  the  exception  of 
the  Finance  Officer,  Parliamentarian,  Correspond- 
ing Secretary,  and  three  (3)  Directors  shall  be 
elected  at  the  annual  meeting  to  serve  for  one 
year.  The  Finance  Officer,  Parliamentarian,  and 
the  Corresponding  Secretary  shall  be  appointed 
by  the  President  and  approved  by  the  Executive 
Committee.  All  officers  with  the  exception  of  the 
President  and  President-Elect  are  eligible  for  re- 
election.  Due  to  the  office  of  President-Elect, 
the  President  cannot  succeed  herself,  but  is  eligi- 
ble to  the  office  for  some  other  year. 

Section  4 — An  Auditor  chosen  by  the  Treasurer 
shall  be  approved  by  the  Executive  Committee. 

ARTICLE  VII— STANDING  COMMITTEES 

Section  1 — The  standing  committees  of  this 
Auxiliary  shall  correspond  as  nearly  as  is  practica- 
ble with  those  of  the  National  and  Southern  Exec- 
utive Committees,  and  shall  include:  Membership; 
Program;  Finance;  Revisions;  Press  and  Publicity; 
News  Circulation;  Memorial;  WASMA  Projects; 
Health  Careers;  Community  Service;  Legislation; 
Archives  and  Exhibits;  Civil  Defense;  Lettie  Daf- 
fin  Perdue  Fund;  Yearbook;  Members-at-Large; 
Bulletin;  Mental  Health;  A.M.E.F.;  Rural  Health; 
Safety;  Auxiliary  to  Student  A.M.A. 

Section  4 — The  Committee  on  Membex’ship  shall 
consist  of  the  Pi'esident-Elect  as  Chairman,  the 
four  Vice-Presidents,  and  the  Chairman  of  Mem- 
bers-at-Large. It  shall  be  the  duty  of  each  Vice- 
President  to  be  responsible  for  an  assigned  district 
to  encourage  organization  of  County  Auxiliaries 
and  to  visit  personally  or  by  delegate  proposed  or 
organized  Auxiliaries.  The  Chairman  of  Mem- 
bers-at-Large  shall  work  with  each  of  the  Vice- 
Presidents  in  enlisting  membei’s-at-large  in  un- 
organized counties. 

Section  5 — The  Committee  on  Programs  shall 
consist  of  the  Chairman  and  four  members  ap- 
pointed by  her.  This  Committee  shall  consult  with 
the  National  Program  Committee  as  to  suitable 
programs  for  county  meetings  and  furnish  material 
for  counties  asking  for  help;  they  shall  prepare 
with  the  aid  of  the  President  in  conjunction  with 
local  arrangement  committee,  programs  for  annual 
meetings. 

Section  C — The  Committee  on  Finance  shall  con- 
sist of  three  members:  its  Chairman  (Finance 

Officer);  the  Ti’easurer;  and  the  immediate  Past 
Treasurer.  It  shall  be  the  duty  of  the  Committee 
on  Finance  to  prepare  a budget  for  presentation 
at  the  pre-convention  meeting  of  the  Executive 
Board,  this  budget  to  cover  proposed  expenditures 
for  the  ensuing  fiscal  year. 

Section  7 — -The  Committee  on  Revisions  shall 
consist  of  a Chairman  and  two  others  appointed 


by  her,  whose  duties  shall  be  to  receive  and  con- 
sider suggestions  for  proposed  amendments  to  the 
Constitution  and  By-Laws  and  present  them  for 
consideration  to  the  Executive  Board  and  the 
members  of  the  Auxiliary  for  final  action.  The 
Chairman  shall  handle  distribution  of  these. 

Section  8 — The  Committee  on  Press  and  Pub- 
licity shall  consist  of  four  members:  A Chairman, 
and  two  othei’s  appointed  by  her,  each  of  whom 
shall  be  from  a city  in  the  State  that  annually  en- 
tertains the  State  Convention.  One  member  shall 
be  from  the  home  city  of  the  President  and  ap- 
pointed by  her.  This  committee  shall  prepare  all 
notices  of  State  interest  for  the  press,  attend  to 
their  publication,  and  clip  and  forward  such  not- 
ices to  the  Historian.  The  Committee  shall  work 
with  Committee  on  Community  Service  on  Radio 
and  T.V. 

Section  9 — The  Committee  on  News  Circulation 
shall  consist  of  four  members:  A Chairman  and 
three  others  appointed  by  her.  It  shall  be  the 
duty  of  this  Committee  to  edit,  publish,  and  dis- 
tribute the  official  publication  of  the  Auxiliary, 
the  WAMASA  News.  The  Chairman  shall  be  re- 
sponsible for  keeping  the  address  file  current  and 
active. 

Section  11 — The  Committee  on  WASMA  Proj- 
ects shall  consist  of  the  Councilor  for  the  Woman’s 
Auxiliax-y  to  the  Southeni  Medical  Association, 
who  shall  serve  as  Chairman,  and  three  or  more 
members  appointed  by  her.  The  duties  of  this 
Committee  will  be  to  publicize  and  carry  out  the 
projects  of  WASMA  and  to  act  as  liaison  between 
that  group  and  the  State  and  component  County 
Auxiliaries. 

Section  12 — The  Committee  on  Health  Cai’eei's 
shall  consist  of  four  members:  The  Chairman  and 
three  others  appointed  by  her.  It  shall  be  the 
duty  of  this  Committee  to  publicize  the  need  for 
nurses  and  methods  of  effective  recruitment,  to 
assist  the  component  County  Auxiliaries  in  nurse 
recruitment  activities,  and  to  cooperate  with  the 
corresponding  National  Committee. 

Section  13 — The  object  of  the  Committee  on 
Community  Service  shall  be  to  inform  itself  con- 
cerning the  activities  of  the  medical  interests  of 
all  clubs,  federations,  charities,  and  other  organi- 
zations; to  advise  the  members  of  the  Auxiliary 
concerning  such  activities  and  the  manner  in  which 
the  trend  of  such  affairs  may  be  influenced  for 
the  good  of  the  public  and  the  advancement  of 
medical  science.  The  Chairman  shall  work  in  co- 
operation with  the  Public  Relations  Director  of 
the  Medical  Association  of  the  State  of  Alabama, 
the  Community  Service  Chairman  of  the  County 
Auxiliaries  and  the  Committees  on  Safety  and 
Publicity.  She  shall  also  be  Radio  and/or  T.V. 
Chairman. 

Section  14 — The  object  of  the  Committee  on 
Legislation  shall  be  to  make  itself  familiar  with 
the  legislation  of  medical  interest  and  to  be  guided 
by  the  Advisory  Committee  of  the  Medical  Asso- 


86 


J.  M.  A.  ALABAMA 


ORGANIZATION  SECTION 


ciation  of  the  State  of  Alabama  along  legislative 
lines. 

Section  15 — The  Committee  on  Archives  and 
Exhibits  shall  consist  of  three  members,  the  Chair- 
man, the  Historian,  and  one  other  member  ap- 
pointed by  the  Chairman.  It  shall  be  the  duty  of 
this  Committee  to  collect  and  file  all  material 
of  national  importance  of  the  State  and  County 
Auxiliaries  for  display  at  the  annual  State  meeting 
and  at  the  annual  meeting  of  the  American  Medi- 
cal Association. 

Section  16 — The  Committee  on  Civil  Defense 
shall  consist  of  the  Chairman  and  three  others 
appointed  by  her.  It  shall  be  the  duty  of  this 
Committee  to  cooperate  with  the  corresponding 
committee  of  the  National  Auxiliary  and  with 
State  and  County  Civil  Defense  authorities  pub- 
licizing the  needs  and  aims  of  the  Civil  Defense 
movement  and  encouraging  county  Auxiliaries  to 
participate. 

Section  18 — The  Committee  on  Yearbook  shall 
consist  of  three  members,  its  Chairman  and  two 
others  appointed  by  her.  It  shall  be  the  duty  of 
the  Committee  to  compile  and  publish  the  Auxili- 
ary' Yearbook. 

Section  21 — The  Committee  on  Mental  Health 
shall  consist  of  the  Chairman  and  three  others 
appointed  by  her.  It  shall  be  the  duty  of  this  Com- 
mittee to  work  in  cooperation  with  the  correspond- 
ing National  Committee  in  assisting  the  State  and 
component  County  Auxiliaries  in  activities  con- 
tributing tow'ard  the  betterment  of  Mental  Health. 

Section  22 — The  Committee  on  American  Medi- 
cal Education  Foundation  shall  consist  of  four 
members,  the  Chairman  and  three  others  appoint- 
ed by  her.  It  shall  be  the  duty  of  this  Committee  to 
solicit  and  collect  funds  from  component  auxili- 
aries and  individual  members,  these  funds  to  be 
forwarded  to  the  American  Medical  Education 
Foundation. 

Section  23 — The  Committee  on  Rural  Health 
shall  consist  of  the  Chairman  and  three  others  ap- 
pointed by  her.  It  shall  be  the  duty  of  this  Com- 
mittee to  cooperate  with  health  agencies  interested 
in  improvement  of  health  conditions  in  rural  areas, 
under  the  advice  and  assistance  of  the  Medical 
Association  of  the  State  of  Alabama. 

Section  24 — The  Committee  on  Safety  shall  con- 
sist of  a Chairman  and  three  others  appointed  by 
her.  This  Committee  shall  encourage  safety  edu- 
cation among  Auxiliary  members  and  cooperate 
with  other  groups  in  the  promotion  of  safety. 

Section  25 — The  Committee  on  Auxiliary  to 
Student  American  Medical  Association  shall  con- 
sist of  a Chairman  and  Co-chairman,  appointed 
by  the  President  and  Executive  Committee  of  the 
Jefferson  County  Auxiliary.  The  Chairman  shall 
serve  as  a regular  member  of  the  State  Board. 


Roll  Call  by  Counties 

The  Recording  Secretary  upon  instructions 
of  the  President  made  a roll  call  by  county. 
The  results  were  as  follows:  Baldwin,  0; 

Blount,  1;  Calhoun,  2;  Clarke,  1;  Coffee,  0; 
Covington,  2;  Colbert,  0;  Cullman,  2;  Dallas, 
0;  DeKalb,  1;  Elmore,  0;  Escambia,  0;  Etowah, 
1;  Geneva,  0;  Houston,  0;  Jackson,  2;  Jefferson 
— Birmingham,  18;  Jefferson — Bessemer,  1; 
Lauderdale,  0;  Madison,  3;  Marion,  2;  Mar- 
shall, 2;  Mobile,  13;  Montgomery,  4;  Morgan, 
1;  Pickens,  1;  Pike,  1;  Talladega,  1;  Tuscaloo- 
sa, 2;  Walker,  0;  Members-at-Large,  3.  Follow- 
ing the  roll  call  there  ensued  a discussion  on 
the  universal  problem  of  improving  attend- 
ance at  meetings. 

Election  of  Officers 

The  following  officers  were  then  elected: 

President-Elect:  Mrs.  W.  A.  Cunningham, 
Birmingham 

First  Vice-President:  Mrs.  J.  O.  Brooks, 
Hamilton 

Second  Vice-President:  Mrs.  John  Kimmey, 
Elba 

Third  Vice-President:  Mrs.  Palmer  H.  War- 
ren, Jackson 

Fourth  Vice-President:  Mrs.  R.  T.  Cale, 
Bessemer 

Treasurer:  Mrs.  James  F.  Crenshaw,  Bir- 
mingham 

Historian:  Mrs.  H.  Price  Edwards,  Birming- 
ham 

Delegates  Miami  Convention:  Mrs.  W.  A. 
Cunningham,  Birmingham;  Mrs.  William  No- 
ble, Fort  Payne;  Mrs.  George  W.  Newburn, 
Jr.,  Mobile;  Mrs.  John  Chenault,  Decatur. 

Alternate  Delegates  Miami  Convention: 
Mrs.  Horace  Bramm,  Huntsville;  Mrs.  Ira 
Patton,  Oneonta;  Mrs.  S.  Goodman,  Birming- 
ham; Mrs.  J.  F.  Crenshaw,  Birmingham. 

It  was  also  decided  that  the  President  shall 
have  the  authority  to  appoint  an  alternate 
delegate  to  the  National  Convention  in  Miami 
in  the  event  the  delegate  and/or  alternate 
delegate  elected  are  unable  to  attend. 


AUGUST  I960— VOL.  30,  NO.  2 


87 


ORGANIZATION  SECTION 


The  duly  elected  officers  were  then  in- 
stalled by  Mrs.  Frank  Gastineau.  Following 
the  installation  of  officers,  Mrs.  W.  G.  Thuss 
presented  the  past-president’s  pin  to  Mrs. 
George  W.  Newburn,  Jr. 

Kcmarks  by  the  New  Presicicii/ 

Mr,v.  John  T.  Morris 

It  is  a privilege  to  serve  you  this  year  and  to> 
work  with  you.  Fronr  the  bottom  of  my  heart,  it 
is  a privilege  to  belong  to  and  to  be  at  a further- 
ing of  the  aims  and  ideals  of  the  Woman’s  Auxili- 
ary to  the  Medical  Association  of  the  State  of 
Alabama.  Do  you  know  that  physicians’  wives  are 
among  the  nicest  people  that  you  can  get  to  know? 
It’s  true. 

Will  you  forgive  me  if  I talk  about  my  kin  folks 
for  a minute?  I come  from  a physician’s  family 
from  way  back.  I can  remember  my  granddaddy 
telling  us  children  on  his  knee  about  his  early 
practice — how  he  started  out  on  the  plains  of 
Nebraska,  back  in  the  ’90’s;  how  my  father  was 
born  in  an  adobe  hut;  how  he  made  house  calls 
with  a horse  and  buggy;  and  how,  for  sport,  he 
chased  jack  rabbits  along  the  way — and  you  know, 
the  jack  rabbits  are  so  fast  out  there  that  they 
would  usually  win.  He  told  us  of  the  many  home 
deliveries  that  he  made — after  which  he’d  crawl 
in  the  buggy  and  curl  up  and  go  to  sleep,  saying, 
“Take  me  home,  Maggie.’’  That’s  the  horse.  And 
when  he’d  wake  up,  it  would  be  to  the  beautiful 
sunlight  that  just  flooded  the  whole  prairie  with 
a golden  glory. 

How  far  away  that  is  in  time  and  culture  from 
today.  Take  my  own  dear  husband,  John,  whom 
I’m  sure  you’ll  learn  more  about  as  time  goes  on. 
To  him  no  sunlight  is  glorious  till  about  noon. 
He  hops  in  his  car,  and  in  about  ten  minutes  he’s 
at  the  hospital  where  he  meets  his  patients  for 
delivery.  Things  have  changed,  haven’t  they? 

I’m  a naive  child;  I come  from  a small  town,  and 
I still  go  around  looking  at  things  with  my  mouth 
wide  open. 

I had  my  first  jet  plane  ride  not  long  ago;  and 
fortunately,  I went  with  John;  I was  scared  to 
death.  I don’t  know  how  many  of  you  have  been 
on  these  jets,  but  they  are  fast.  John  was  just 
embarrassed  to  death;  he’s  an  old  seasoned  trav- 
eler. As  I climbed  up  the  gang  plank,  he  said, 
“Hon,  just  be  quiet  now;  don’t  embarrass  me.” 
We  got  on  the  plane;  and  well,  I had  to  look  at 
all  the  pretty  furnishings  and  the  seats  that  go 
back  and  forth  and  the  safety  belt.  He  was  wish- 
ing that  he  did  not  have  to  claim  me  at  all.  Final- 
ly he  said,  “Now  look.  Honey,  if  you’ll  just  shut 
your  eyes  until  we  are  up  in  the  air,  you  won’t  be 
scared.”  So  I shut  my  eyes  and  hung  on  real 
tight.  After  a little  bit,  I heard  the  engines  warm 


up.  Then  it  was  a little  bit  bumpy;  and  all  of  a 
suuden,  it  got  nice  and  smooth.  And  I opened 
my  eyes.  I said,  “Honey,  this  isn’t  hard  at  all. 
Lock,  we’re  up  in  the  air  already.”  And  I looked 
ou  the  window,  “Why  see;  the  people  down  there 
look  like  ants  already;  this  is  wonderful!”  He 
said,  “Honey,  will  you  please  hush;  we  aren’t  off 
the  ground  yet.  Those  are  ants.” 

While  we  are  talking  about  the  jet  age,  let’s 
look  at  our  own  Auxiliary  for  a moment.  What 
is  our  fundamental  purpose?  Not  long  ago  I had 
a letter  from  a friend  of  mine — let’s  call  her  Ann — 
who  was  a student  nurse  when  I knew  her  several 
years  ago,  a very  charming  girl  who  married  a 
handsome  young  intern.  Her  letter  said:  “It’s 

been  five  years  since  you  heard  from  me,  and  we 
are  now  established  in  practice.  Now,  we  have 
an  income  that  is  adequate  for  us  and  the  children, 
but  we’ve  paid  a terrible  price  in  bitterness.  How 
much  it  would  have  helped  if  someone  had  re- 
assured us  that  we  would  survive — it  someone  had 
just  said,  ‘We’ve  been  through  this,  and  we  made 
it.  You  will  tool’  But  no  one  said  that  to  us.” 

There  was  another  young  lady  whom  I met  not 
too  long  ago  when  I visited  an  unorganized  county. 
We  were  talking  about  what  an  Auxiliary  might 
do,  could  do,  perhaps,  even  should  do.  This  is  what 
Shirley  said:  “We’ve  been  here  exactly  one  year; 
and  if  we  had  had  an  Auxiliary  functioning  as  you 
say  one  should,  it  would  have  been  so  much  easier 
for  us.” 

Well,  are  you  saying,  “Nobody  helped  me!  No- 
body helped  us”?  Have  you  extended  your  hand 
in  friendly  welcome  to  the  new  members  in  your 
area? 

You  know  our  own  organization  has  grown  by 
leaps  and  bounds  in  the  very  last  few  years.  Your 
State  and  National  Auxiliaries  invest  in  the  train- 
ing of  your  President  and  President-Elect;  they 
feel  that  it  is  important.  You  have  an  investment 
in  our  training.  I don’t  know  about  you,  but  I’m 
Scotch;  and  I like  to  get  my  money’s  worth.  I 
don’t  mind  spending  it  if  I get  something  in  re- 
turn; but  when  I don’t,  it  burns  me  up.  You  owe 
it  to  yourselves  to  get  your  money’s  worth  from 
our  training,  but  you  can’t  do  it  unless  y o u r 
President  and/or  your  President-Elect  visits  your 
Auxiliary  and  talks  with  you  about  your  problems. 

You  don’t  have  to  entertain.  Now  I love  a party; 
but  when  I’m  home,  I have  to  do  my  own  house- 
work, the  gardening,  and  the  yardwork.  I know 
what  is  involved.  You  don’t  have  to  listen  to  any 
grand  speeches  unless  you  want  to.  But  you  do 
need  that  visit,  and  you  need  to  feel  free  to  discuss 
your  problems  with  us.  We  are  here  today  because 
you  want  us  to  help.  With  thirty  county  auxili- 
aries, it  is  imperative  that  visits  to  nearby  counties 
be  grouped  together.  Please,  help  us  do  this.  It’s 
for  you. 

We  need  a greater  understanding  of  what  the 
national  program  is.  You’ll  get  more  out  of  it  if 
you  will  have  a full  day-and-a-half  workshop  at 


88 


J.  M.  A.  ALABAMA 


ORGANIZATION  SECTION 


the  fall  Board  meeting  or  if  you  will  set  up  dis- 
trict meetings  at  which  you  inform  yoursel\  es. 
You  need  a greater  representation  on  your  State 
Board.  We  need  our  committees  functioning  as 
our  Handbook  suggests.  And  one  other  thin^,  I 
want  to  paraphrase  our  own  Southern  President, 
Mrs.  Chenault.  It  has  to  do  with  binding  your 
husband.  We  are  an  Auxiliary;  and  any  course 
of  action  that  we  undertake,  either  local  or  state, 
should  be  with  the  approval  of  the  Society  to  which 
we  are  an  Auxiliary.  And  likewise,  that  which 
a Society  is  asked  by  an  Auxiliary  to  do  should 
be  accepted  by  it,  if  it  is  at  all  possible  to  do  so. 

You  know,  you  have  a terrific  potential.  Have 
you  ever  seen  a teetering  rock,  one  that  sits  on 
top  of  a high  mountain  over  near  the  edge?  It  has 
a potential  force.  It  has  been  sitting  there  for 
years,  growing  moss;  but  it  could  come  crashing 
down,  destroying  everything  in  its  way.  Or  if  it 
were  tied  to  a rope  and  lowered  slowly,  it  could 
pull  a heavy  car  out  of  the  ditch.  Well,  medically, 
we  are  teetering  rocks  too.  Please,  don’t  just  grow 
moss;  be  a positive  factor.  We  represent  our  hus- 
bands in  all  communities.  Deal  in  kindness  and 
understanding,  in  tolerance,  and  with  good  deeds; 
for  these  things  are  sort  of  like  paint.  With  fresh 
paint  you  can  make  things  beautiful;  but  when 
you  just  leave  it  in  its  can,  it  dries  out. 

As  we  work  together  this  year,  I hope  we  will 
have  a lot  of  fun.  I hope  we’ll  get  to  know  each 
other  much  better  and  that  we  will  grow  in  love 
and  respect  for  all  our  Auxiliary  members  and  for 
our  men  folks  in  their  greater  Society. 


Appo’mtmaits 

The  President  appointed  the  following  of- 
ficers: Finance  Officer,  Mrs.  John  Slaugh- 

ter; Corresponding  Secretary,  Mrs.  L.  H. 
Clemmons;  Parliamentarian,  Mrs.  W.  G. 
Thuss,  Sr. 

The  following  chairmen  and  committee 
members  were  then  appointed:  Mrs.  Seaburt 
Goodman,  Chairman,  A.M.E.F.;  Mrs.  James 
Morgan,  Jr.,  Co-Chairman,  A.M.E.F.;  Mrs. 
George  S.  Peters,  Chairman,  Archives  and 
Exhibits;  Mrs.  William  Noble,  Chairman, 
Bulletin;  Mrs.  Horace  Bramm,  Member,  Bul- 
letin; Mrs.  Oscar  Dahlene,  Chairman,  Civil 
Defense;  Mrs.  E.  V.  Caldwell,  Member,  Civil 
Defense;  Mrs.  T.  M.  Owens,  Chairman,  Com- 
munity Service;  Mrs.  Winston  A.  Edwards, 
Chairman,  Legislation;  Mrs.  A.  D.  Henderson, 
Chairman,  Lettie  Daffin  Perdue  Fund;  Mrs. 
W.  E.  Stinson,  Chairman,  Members-at-Large; 
Mrs.  James  Guin,  Chairman,  Health  Careers; 


Mrs.  Earl  B.  Wert,  Member,  Health  Careers; 
Mrs.  G.  L.  Ross,  Member,  Health  Careers; 
Mrs.  W.  A.  Cunningham,  Chairman,  Member- 
ship; Mrs.  John  F.  Holley,  Chairman,  Memo- 
rial; Mrs.  R.  L.  Tourney,  Chairman,  Mental 
Health;  Mrs.  Thomas  Wright,  Member,  Men- 
tal Health;  Mrs.  William  Brock,  Chairman, 
WAMASA  News;  Mrs.  Sim  Penton,  Co-Chair- 
man, WAMASA  News;  Mrs.  John  Kent, 
Chairman,  WAMASA  News  Circulation;  Mrs. 
J.  H.  Farrior,  Chairman,  Press  and  Publicity; 
Mrs.  Roy  Williams,  Member,  Press  and  Pub- 
licity; Mrs.  W.  O.  Romine,  Member,  Press  and 
Publicity;  Mrs.  David  Mullins,  Member,  Press 
and  Publicity;  Mrs.  Ira  Patton,  Chairman, 
Programs;  Mrs.  Lewis  Kirkland,  Member, 
Programs;  Mrs.  J.  R.  Horn,  Chairman,  Revi- 
sions; Mrs.  Sam  Cohn,  Chairman,  Safety; 
Mrs.  Francis  Nicholson,  Member,  Safety;  Mrs. 
Don  King,  Member,  Safety;  Mrs.  William  No- 
ble, Member,  Safety;  Mrs.  George  Newburn, 
Jr.,  Chairman,  Woman’s  Auxiliary  to  S.M.A. 
Project;  Mrs.  Robert  Grady,  Chairman,  Aux- 
iliary to  S.A.M.A.;  Mrs.  J.  C.  Chambliss, 
Chairman,  Yearbook;  Mrs.  W.  J.  Rosser, 
Chairman,  Special  Project  Essay  Contest. 

There  being  no  further  business,  the  Sec- 
ond General  Session  was  adjourned. 

Liutcbeott,  Battle  House  Hotel 

Mrs.  Dixon  Meyers,  President  of  the  Wom- 
an’s Auxiliary  to  the  Mobile  County  Medical 
Society,  presided. 

Dr.  W.  R.  Carter,  President  of  the  Medical 
Association  of  the  State  of  Alabama,  brought 
greetings  from  the  State  Medical  Association 
to  the  Auxiliary. 

Invocation  was  given  by  Mrs.  Jack  Yeager. 

The  tellers  reported  that  Mesdames  New- 
burn, Caldwell,  Hunt,  Smith,  and  Howell  had 
been  elected  to  the  Nominating  Committee. 

Mrs.  Seaburt  Goodman,  Chairman  for  A.M. 
E.F.,  presented  certificates  of  achievement 


AUGUST  I960— VOL.  30,  NO.  2 


89 


ORGANIZATION  SECTION 


to  the  following  Auxiliaries:  Blount,  Clarke, 
Coffee,  Covington,  Cullman,  Elmore,  Geneva, 
Jackson,  Jefferson — Bessemer,  Jefferson — 
Birmingham,  Madison,  Marion,  Pickens,  and 
Tuscaloosa. 

Mrs.  Robert  Cowden  presented  Hobby 
Show  Awards  to  the  following:  Mrs.  E.  T. 

Doehring  in  the  Creative  Arts  Division,  Mrs. 
Shephard  Jerome  in  the  Handicraft  Division, 
Dr.  Robert  Cowden  in  the  Photography  Divi- 
sion, Benjamin  Kimbrough  and  Jerry  Beck  in 
the  Children’s  Division. 

Mrs.  W.  G.  Thuss  introduced  Mrs.  Frank 
Gastineau,  President  of  the  Woman’s  Auxil- 
iary to  the  American  Medical  Association. 

Keniarks  hy  Mrs.  Frank  Gastineau 

Our  real  purpose  in  getting  together  at  state 
meetings  is  to  obtain  knowledge  and  information 
that  will  arouse  enthusiasm  and  create  a better 
spirit.  Thus,  by  the  time  that  we  return  to  our 
homes,  we  put  more  punch  and  more  vigor  into  the 
program  work  of  our  organization. 

I know  it  is  very  gratifying  to  your  President 
that  members  are  here  fi’om  all  over  the  state 
to  share  experience  and  contribute  something 
worthwhile  to  friends  and  fellow  members.  I want 
to  tell  you  how  much  we  appreciate  your  Auxiliary 
work  in  Alabama,  and  I know  Dot  Newburn  has 
been  an  inspiration  to  all  of  you.  I certainly  en- 
joyed knowing  Dot,  and  I am  having  her  spotted 
in  my  official  family  in  the  A.M.A.  Auxiliary. 

I want  to  tell  you  something  that  you  probably 
don’t  all  know,  and  that  is  Louise  Thuss  has  been 
selected  by  the  Nominating  Committee  for  the  Of- 
fice of  First  Vice-President  of  the  Woman’s  Auxili- 
ary to  the  American  Medical  Association.  That’s 
a step  up  for  Louise;  and  it’s  good  news  for  all 
of  us,  because  believe  me,  when  it  comes  to  mem- 
bership, I think  Louise  is  better  qualified  than 
anybody  in  the  whole  Auxiliary  in  the  whole 
United  States.  I know  we  are  going  to  have  a big 
increase  in  membership.  That’s  just  exactly  what 
we  need;  and  if  anybody  can  get  it,  Louise  can. 

You  are  really  going  to  get  off  lucky  today  be- 
cause you  could  have  a harder  time  than  I am  go- 
ing to  give  you.  It’s  only  because  I’ve  had  a lot  of 
experience  that  I am  not  going  to  make  as  long  a 
talk  as  I would  like  to  make.  I learned  the  hard 
way  on  the  very  first  trip  I ever  made  in  Indiana 
when  I was  President  of  my  State  Auxiliary.  I was 
asked  to  attend  the  conference  of  Presidents  and 
Presidents-Elect  in  Chicago,  and  on  returning  I 
was  so  full  of  my  subject  that  I had  a whole  note- 
book full  of  notes.  I talked  about  every  subject 
under  the  sun — everything  on  the  program.  I really 


told  them  everything.  The  sad  part  of  it  was  that  I 
thought  they  had  come  to  hear  me,  but  they  hadn’t. 

It  was  a zero  day  with  ice  all  over  everything. 
I had  to  take  a bus  to  get  to  this  town,  and  I got 
off  the  bus  and  had  to  skate  about  a mile  to  get 
there.  When  I got  there,  I saw  all  of  these  women. 
And  I said,  “Gee,  they  all  came  to  hear  me.”  I 
found  out  they  were  having  a pitch-in.  I had 
never  attended  a pitch-in  before;  everybody,  I 
learned  later,  came  to  eat.  They  all  ate  and  ate 
and  ate — because  you  sampled  your  neighbors 
cooking  which  was  just  wonderful.  I can  remem- 
ber it  as  if  it  were  yesterday.  They  sat  me  in  a 
corner  in  the  living  room  in  an  old  rocking  chair. 
Everybody  ate  all  they  could  hold,  and  then  they 
said  I could  talk.  Well,  then  is  when  I gave  them 
that  long,  long  talk.  When  I got  through  with  ev- 
erything, one  woman  over  in  the  corner  stood  up 
and  said,  “Well,  Mrs.  Gastineau,  we  are  awfully 
disappointed.  We’ve  tried  everything  that  you’ve 
talked  about,  and  we  are  not  interested  in  a single 
one  of  those  things.  We  thought  that  you’d  tell 
us  something  new.”  Now,  I know  you  won’t  do 
that  to  me  here  because  you  are  too  polite  in  the 
Deep  South;  but  that  can  happen  to  people  in 
Indiana. 

I am  only  going  to  talk  to  you  about  one  thing 
today;  so  bear  up,  and  I’ll  try  to  talk  fast. 

My  year  as  President  of  the  Woman’s  Auxiliary 
is  drawing  to  a close,  and  I can  say  that  it  brought 
many  rewards  and  few  problems.  I know  that  I 
was  the  one  who  gained  the  most  from  the  thou- 
sands of  miles  I have  traveled  by  train  and  plane 
and  bus,  from  coast  to  coast  and  border  to  border. 

In  all  of  my  talks  on  radio  and  television,  as 
well  as  press  interviews  during  the  past  months, 
I have  tried  to  explain  a few  of  the  many  worth- 
while health  activities  we  are  engaged  in.  It  is 
amazing  to  me,  however,  that  there  are  still  many 
intelligent,  well-educated  persons  who  are  almost 
completely  ignorant  of  the  purposes,  the  objectives, 
the  ideals,  and  the  hopes  of  the  medical  profession. 
It  is  not  strange,  therefore,  that  the  general  pub- 
lic is  poorly  informed  on  many  points  about  which 
the  medical  profession  is  challenged  and  criticised 
today.  It  is  up  to  our  members  to  provide  the 
right  answers  and  to  set  the  record  straight. 

There  is  no  limit  to  auxiliary  members’  influ- 
ence and  their  ability  to  help  other  people  under- 
stand the  facts,  especially  as  they  relate  to  hos- 
pital costs,  drug  costs,  insurance  claims,  and  doc- 
tors’ fees.  In  carrying  our  message  to  the  public, 
let  us  not  ignore  the  simplest,  least  expensive  and 
most  effective  medium  of  communication — word 
of  mouth,  neighbor  to  neighbor  and  person  to  per- 
son. The  whole  field  of  good  medical  public  re- 
lations lies  before  you. 

I want  to  talk  to  you  for  just  a little  while  about 
our  big  concern  and  about  what  we,  as  individuals, 
must  do.  Our  failure  in  the  past  to  interest  our- 
selves in  the  affairs  of  the  community  is  one  reason 
why  so  many  other  groups  have  run  off  with  the 


90 


J.  M.  A.  ALABAMA 


ORGANIZATION  SECTION 


ball  in  health  matters.  When  the  enlightened  peo- 
ple in  the  community  abdicate  their  responsibili- 
ties, it  is  inevitable  that  the  least  qualified  move 
into  the  vacuum  or  that  a strong  central  govern- 
ment will  take  over,  removing  to  a large  extent 
the  peoples’  right  to  govern  themselves. 

I know  that  you  have  been  actively  engaged  in 
defeating  the  Forand  Bill  and  are  happy  that  it 
has  been  kept  in  Committee.  All  Auxiliaries  have 
worked  valiantly  to  accomplish  this.  But  we  can- 
not stop  now.  A substitute  bill  has  been  promised 
and  is  practically  assured  by  election  day.  This 
continues  to  be  a crucial  time. 

All  of  us  know  that  this  legislation  is  nothing 
more  than  tricky  compulsory  federal  health  insur- 
ance coming  in  the  back  door.  The  enactment  of 
this  type  of  legislation  would  be  followed  by  con- 
trol of  the  health  care  of  the  aged  by  the  social 
security  system.  We  know'  there  is  no  emergency, 
that  present  social  security  cash  benefits,  private 
pension  plans,  increased  savings,  and  liquid  assets 
are  all  combining  to  improve  steadily  the  economic 
resources  and  purchasing  power  of  the  group  over 
sixty-five. 

A new  psychological  climate  for  the  aging  is  be- 
ing created  in  productive  utilization  in  society. 
New  hospital  design,  more  suitable  economical  care 
of  the  ambulatory  aged,  homemaker  services,  home 
care  services,  improved  medical  care,  and  other 
positive  action  programs  are  proceeding  at  a rapid 
rate.  Voluntary  and  governmental  enterprise  that 
preserve  individual  responsibility  and  free  choice 
have  teamed  up  and  are  moving  rapidly  to  resolve 
other  problems  still  remaining.  To  socialize  medi- 
cal care  by  tunneling  its  services  through  the  social 
security  system  would  supply  a cure,  but  the  cure 
would  be  worse  than  the  disease  in  the  ultimate 
effects  on  individual  freedom. 

One  of  the  chief  difficulties  older  people  have 
is  caused  by  inflation.  And  what  causes  inflation? 
It  is  the  wild  government  spending,  the  fantastic 
deficit  and  debt  which  liberals  over  the  years  have 
saddled  this  nation  with.  The  solution  for  all  the 
people,  including  older  ones,  is  not  still  more  reck- 
less spending,  deficit,  debt  and  inflation.  The  right 
way  is  to  halt  this  massive  irresponsibility  with  the 
peoples’  money  by  curbing  spending  and  lowering 
taxes.  Every  member  of  our  Auxiliary  must  fight 
this  kind  of  proposed  federal  legislation  in  her  own 
backyard.  That  is  where  the  w'ork  on  behalf  of 
medicine  can  be  most  effective.  Tell  your  neigh- 
bors and  your  friends  and  your  club  members  and 
the  grocer  down  the  street  what  you  think  about 
Forand-type  legislation,  about  Senator  Kennedy’s 
big  health  dreams,  and  all  the  others.  Tell  them 
why  it  is  bad  legislation  for  them.  What  do  you 
ever  get  from  the  government  that  is  free?  It  is  a 
known  fact  that  for  every  three  dollars  you  send 
to  Washington  you  get  only  one  back.  Just  re- 
member that  every  time  the  government  hands 
you  a bouquet,  it  was  picked  in  your  own  garden. 
One  resolution  adopted  by  the  A.M.A.  House  of 
Delegates  is  directed  as  much  to  Auxiliary  mem- 


bers as  to  their  husbands:  “All  physicians  should 
endeavor  to  understand  the  socio-economic  aspects 
of  the  world  in  which  we  live,  not  because  they  are 
physicians  or  members  of  the  American  Medical 
Association  but  because  they  are  citizens.  Your 
Reference  Committee  solemnly  urges  all  physi- 
cians to  participate  more  fully  in  community  ac- 
tivity and  socio-economic  matters  in  your  own 
community.’’ 

Now,  this  resolution  calls  for  action  by  physi- 
cians and  their  wives,  also.  Everyone  is  concerned 
about  our  elderly  citizens  today;  and  if  we  wish 
to  do  something  for  them,  there  is  much  that  we 
can  do  to  prepare  ourselves  and  educate  others 
for  these  extra  years  that  are  being  added  to  our 
life  span.  For  example,  improvement  in  physical 
well-being  could  be  accomplished  by  weight  re- 
duction programs  in  28  per  cent  of  the  American 
people;  education  and  mental  hygiene  programs 
could  produce  more  happiness  and  less  frustration 
for  more  people;  increased  use  of  physical  educa- 
tion preserves  man’s  physical  body  and  prevents 
many  disabling  diseases;  habits  of  study  and  men- 
tal activity  keep  people  living  to  advanced  years 
from  suffering  any  loss  as  far  as  intellectual  abili- 
ties and  capacities  are  concerned,  and  rehabilita- 
tion of  the  aged  person  pays  as  large  a dividend 
as  rehabilitation  of  the  young.  Let  us  accentuate 
the  positive  in  our  plans  for  helping  the  older 
citizen. 

There  is  no  limit  to  an  Auxiliary  member’s  in- 
fluence and  her  ability  to  help  other  people  un- 
derstand the  facts.  Let  us  alert  our  neighbors  to 
the  two  major  dangers  that  can  confront  us  from 
our  national  government  today — its  growth  in 
power  and  indebtedness  and  its  assumption  of  per- 
sonal rights  and  freedoms.  As  prosperity  and  op- 
portunity and  literacy  have  developed,  there  should 
have  been  a corresponding  decrease  in  welfare- 
isms  and  governmental  support.  It  should  not  be 
our  biggest  business. 

All  of  our  members  are  mothers,  potential  moth- 
ers, and  grandmothers;  but  we  have  grown  up  in 
a country  that  in  the  past  has  had  greater  freedom 
than  any  other  country  in  the  world.  You  have 
seen  changes  limiting  our  freedom  a little  more 
each  year.  And  you  know  that  once  we  lose  a 
freedom,  we  never  gain  it  back.  If  you  desire  to 
save  for  your  children  and  your  children’s  children 
the  benefits  which  you  have  enjoyed,  you  must 
become  more  vocal,  more  active;  you  must  become 
more  persuasive  and  more  determined  to  protect 
those  things  which  you  hold  dear. 

Following  the  luncheon  there  was  a style 
show  presented  by  Metzger’s. 

Mrs.  George  W.  Newburn,  Jr.  entertained 
the  members  later  in  the  afternoon  at  an  open 
house  at  her  home. 


AUGUST  I960— VOL.  30,  NO.  2 


91 


ORGANIZATION  SECTION 


Registration  at  the  1960  Meeting 


MEMBERS 

Mrs.  Charles  E.  Abbot,  Jr. 
Mrs.  Vaun  Adams 
Mrs.  Ernest  B.  Agee,  Jr. 
Mrs.  Homer  Allgood 
Mrs.  J.  R.  Armistead 
Mrs.  W.  A.  Askew 
Mrs.  B.  F.  Austin 
Mrs.  J.  H.  Baumhauer 
Mrs.  Chester  Beck 
Mrs.  J.  S.  P.  Beck 
Mrs.  Irwin  Boozer 
Mrs.  J.  O.  Brooks 
Mrs.  Claude  Brown 
Mrs.  J.  L.  Brown 
Mrs.  E.  T.  Brunson 
Mrs.  Dan  Burke 
Mrs.  L.  R.  Burroughs,  Jr. 
Mrs.  O.  L.  Burton 
Mrs.  B.  F.  Caffey 
Mrs.  E.  V.  Caldwell 
Mrs.  Robert  T.  Cale 
Mrs.  S.  J.  Campbell 
Mrs.  J.  C.  Carmichael 
Mrs.  Ben  M.  Carraway 
Mrs.  Gordon  Carroll 
Mrs.  W.  R.  Carter 
Mrs.  Frank  L.  Chenault 
Mrs.  John  Chenault 
Mrs.  O.  W.  Clayton 
Mrs.  L.  H.  Clemmons 
Mrs.  H.  D.  Coe,  Jr. 

Mrs.  Jack  T.  Coleman 
Mrs.  C.  S.  Cotlin 
Mrs.  A.  M.  Cowden 
Mrs.  Robert  Cowden 
Mrs.  T.  D.  Cowles 
Mrs.  J.  M.  Crawford 
Mrs.  James  F.  Crenshaw 
Mrs.  Joe  Cromeans 
Mrs.  W.  G.  Cumbie 
Mrs.  W.  A.  Cunningham 
Mrs.  Oscar  Dahlene,  Jr. 
Mrs.  Harold  Davis 
Mrs.  F.  H.  DeVane 
Mrs.  R.  A.  Dillard 
Mrs.  Albert  S.  Dix 
Mrs.  J.  H.  Dodson 
Mrs.  James  G.  Donald 
Mrs.  Thomas  C.  Donald,  Jr. 
Mrs.  Edward  A.  Dudley,  Jr. 
Mrs.  J.  E.  Dunn 
Mrs.  H.  Price  Edwards 
Mrs.  Winston  A.  Edwards 
Mrs.  Frank  England 
Mrs.  Marshall  Eskridge 
Mrs.  Paul  D.  Everest 
Mrs.  Ray  Evers 
Mrs.  J.  H.  Farrior 
Mrs.  W.  C.  Folsom 


Mrs.  Lonnie  W.  Funderburg 
Mrs.  James  H.  Gentry 
Mrs.  J.  Henry  Goode 
Mrs.  Seaburt  Goodman 
Mrs.  Hugh  Gray 
Mrs.  Sidney  Gray,  Jr. 

Mrs.  Richard  J.  Grayson 
Mrs.  A.  Huey  Green 
Mrs.  James  C.  Guin,  Jr. 

Mrs.  Toxey  Haas 
Mrs.  Kenneth  M.  Hannon 
Mrs.  Edward  A.  Harris 
Mrs.  A.  D.  Henderson 
Mrs.  Luther  Hill 
Mrs.  L.  H.  Hinton 
Mrs.  Durwood  Hodges 
Mrs.  Claude  Holland 
Mrs.  Julian  Howell 
Mrs.  Joe  Humphries 
Mrs.  Marston  Hunt 
Mrs.  Shepard  Jerome 
Mrs.  Bruce  K.  Johnson 
Mrs.  Leslie  M.  Johnson 
Mrs.  James  M.  Jones,  Jr. 

Mrs.  J.  S.  Jordan 
Mrs.  Otis  Jordan 
Mrs.  Julian  Keller 
Mrs.  John  E.  Kent 
Mrs.  C.  D.  Killian 
Mrs.  B.  B.  Kimbrough 
Mrs.  R.  W.  Kramer 
Mrs.  W.  S.  Littlejohn 
Mrs.  George  March 
Mrs.  C.  N.  Matthews 
Mrs.  O.  C.  McCarn 
Mrs.  John  McGehee 
Mrs.  Max  V.  McLaughlin 
Mrs.  Thomas  A.  Melton 
Mrs.  W.  E.  Metzger 
Mrs.  Dixon  Meyers 
Mrs.  John  P.  Mims 
Mrs.  J.  M.  Morgan,  Jr. 

Mrs.  John  T.  Morris 
Mrs.  A.  V.  Mortensen 
Mrs.  Ed  Morton 
Mrs.  L.  R.  Murphree 
Mrs.  Robert  Nelson,  Jr. 

Mrs.  C.  W.  Neville 
Mrs.  G.  W.  Newburn,  Sr. 

Mrs.  George  W.  Newburn,  Jr. 

Mrs.  L.  D.  Newman 

Mrs.  William  Noble 

Mrs.  J.  Coleman  O’Gwynn,  Jr. 

Mrs.  Arthur  Owens 

Mrs.  T.  M.  Owens 

Mrs.  Ira  Patton 

Mrs.  William  B.  Patton 

Mrs.  John  Day  Peake 

Mrs.  J.  A.  Pennington 


Mrs.  H.  R.  Pepper 

Mrs.  Sidney  Phillips 

Mrs.  Woodrow  Polewoda 

Mrs.  Cecil  E.  Price 

Mrs.  John  D.  Rayfield 

Mrs.  Frank  W.  Riggs 

Mrs.  Mack  J.  Roberts 

Mrs.  Brison  Robertson,  Jr. 

Mrs.  W.  O.  Romine 

Mrs.  W.  J.  Rosser 

Mrs.  S.  N.  Rumpanos 

Mrs.  W.  M.  Salter 

Mrs.  Robert  A.  Sammons 

Mrs.  Edwin  Scott 

Mrs.  Alwyn  A.  Shugerman 

Mrs.  Robert  C.  Simmons,  Jr. 

Mrs.  John  M.  Slaughter 

Mrs.  Curtis  A.  Smith 

Mrs.  R.  J.  Smith 

Mrs.  William  L.  Smith 

Mrs.  J.  Ellis  Sparks 

Mrs.  Dan  Sullivan 

Mrs.  W.  R.  Sutton 

Mrs.  Albert  Tatum 

Mrs.  Charles  D.  Terry 

Mrs.  W.  G.  Thuss 

Mrs.  Robert  L.  Tourney 

Mrs.  E.  L.  Trammell 

Mrs.  W.  H.  Tucker 

Mrs.  Norman  Veale 

Mrs.  H.  S.  Walker,  Jr. 

Mrs.  Rhett  Walker 
Mrs.  Palmer  H.  Warren 
Mrs.  A.  L.  Watson 
Mrs.  John  W.  Webb,  Jr. 

Mrs.  H.  N.  Webster,  Jr. 

Mrs.  Joseph  E.  Welden 
Mrs.  E.  B.  Wert 
Mrs.  Ernest  West 
Mrs.  William  E.  White 
Mrs.  James  Williams 
Mrs.  James  Williams,  Jr. 
Mrs.  Robert  K.  Wilson,  Jr. 
Mrs.  William  Wright 
Mrs.  Jack  Yeager 
Mrs.  Chestley  Yelton 

MEMBERS-AT-LARGE 

Mrs.  T.  J.  Anderson 
Mrs.  Eugene  H.  Bradley 
Mrs.  W.  W.  Eddins 
Mrs.  J.  Paul  Jones 
Mrs.  Lewis  Kirkland 
Mrs.  R.  J.  McLaughlin 
Mrs.  G.  E.  Newton 
Mrs.  Thomas  B.  Norton 
Mrs.  J.  A.  Sherrod,  Jr. 

Mrs.  William  W.  White 


92 


J.  M.  A.  ALABAMA 


MEDICINE  AS  A CAREER 

CHANDLER  BRAMLETT 


The  practice  of  healing,  in  some  form,  is  as 
old  as  man  himself.  Although  for  centuries 
it  was  primitive  and  very  crude,  going 
through  waves  of  charlatans  and  other  fak- 
ers, medicine  in  the  last  hundred  years  has 
given  man  a new  lease  on  life. 

Modern  medicine  began  in  the  nineteenth 
century,  due  mainly  to  the  work  of  Pasteur 
and  Lister  with  minute  particles  called  mi- 
crobes. Today  we  know  these  microbes  un- 
der the  heading  of  bacteria. 

Due  to  our  increased  knowledge  of  disease 
today,  our  present  life  span  has  hit  an  all 
time  high.  Child-birth  and  neonatal  deaths 
are  at  the  lowest  in  the  history  of  man. 

These  two  facts  bring  into  focus  the  main 
reasons  for  the  growing  population.  How- 
ever, in  the  November  9 issue  of  U.  S.  News 
& World  Report,  according  to  the  Surgeon 
General’s  office,  the  amount  of  doctors  per 
100,000  people  has  decreased  from  143.4  to 
140.7.  At  this  present  rate  the  estimated 
amount  of  physicians  per  100,000  people  in 
1975  will  be  only  133.2. 

The  U.  S.  public,  now  more  health  con- 
scious than  ever  before,  pays  an  average  of 
five  visits  a year  per  capita  to  doctors  where 
only  thirty  years  ago  they  made  only  three 
visits  a year  per  capita  to  doctors. 


Mr.  Bramlett  is  a graduate  of  Murphy  High 
School,  Mobile,  Alabama,  and  his  above  essay  won 
third  place  in  the  Association’s  essay  contest  this 
year. 


With  all  these  figures  brought  into  light 
it  is  easily  seen  why  medicine  is  one  of  our 
most  important  fields  today  and  why  there  is 
a growing  demand  for  more  doctors.  This 
indicates  that  the  adequately  trained  physi- 
cian will  be  in  constant  demand  by  the  health 
conscious  public. 

Man  is  instinctively  endowed  with  the  de- 
sire to  help  his  fellow  man  when  he  is  ill  or 
injured.  Therefore,  when  one  is  able  to  ren- 
der service  to  help  those  in  need,  he  has  an 
inward  reward  which  cannot  be  equaled  by 
any  other  vocation  or  profession. 

It  is  interesting  to  note  that  of  the  thirty- 
two  miracles  performed  by  Christ,  twenty- 
seven  have  to  do  with  the  healing  of  the 
maimed,  the  sick,  or  the  injured.  The  action 
of  Jesus  Christ  clearly  points  the  picture 
showing  that  the  good  physician  is  really  do- 
ing the  Lord’s  work  in  the  practice  of  his  pro- 
fession. 

The  challenge  of  the  unknown,  the  explo- 
lation  of  new  approaches  to  conquer  certain 
dread  diseases  develops  for  the  educated  phy- 
sician the  additional  stimulant  of  solving  a 
problem  never  yet  solved  by  man.  Again  one 
may  draw  the  comparison  that  man,  through- 
out history,  starting  with  Adam  and  Eve’s  de- 
sire to  leave  the  Garden  of  Eden,  Columbus’ 
desire  to  find  a new  route  to  India,  to  man’s 
present  day  desire  to  conquer  space  is  the 
same  as  the  truly  devoted  doctor’s  desire  to 
rid  the  people  of  the  Earth  of  disease  and  sick- 
ness. 

However,  a word  of  caution  must  be  in- 


AUGUST  I960— VOL.  30,  NO.  2 


93 


THE  ASSOCIATION  FORUM 


serted  for  the  benefit  of  all  those  who  think 
they  want  to  be  doctors.  To  become  a phy- 
sician a person  must  spend  anywhere  from 
nine  to  fifteen  years  in  graduate  and  post- 
graduate work.  He  may  see  his  high  school 
friends  established  and  very  successful  in 
their  businesses  while  he  is  still  in  school. 
This  often  can  discourage  and  dishearten  a 
potential  physician  and  send  him  into  some 
other  field  that  is  easier.  But,  once  he  has 
received  his  degree,  it  is  then  the  hard  part 
begins.  The  life  of  a physician  is  so  demand- 
ing that  his  time  is  not  his  own  and  nothing 
must  take  precedence  over  his  practice  of 
medicine.  To  be  a truly  good  doctor,  one 
must  realize  this  and  abide  by  it  or  become  a 
failure.  Where  the  common  man  is  fighting 
for  less  than  a forty  hour  week,  time  and  a 
half  for  overtime,  and  other  similar  items, 
the  average  doctor  puts  in  between  sixty  and 
eighty  hours  a week.  Even  less  of  this  time 
is  now  spent  for  house  calls.  The  average  doc- 
tor sees  over  one  hundred  patients  a week,  a 
stiff  pace  for  any  person  to  keep. 

There  are  also  many  advantages  to  be 
found  in  the  medical  profession.  The  physi- 
cian with  a private  practice  is  his  own  boss. 
He  does  not  work  for  anyone  else.  However, 
the  individual  physician’s  practice  of  medi- 
cine, without  the  undue  restrictions  and  con- 
trols by  others  who  do  not  bear  the  responsi- 
bility, could  possibly  lead  to  dangerous  con- 
sequences. He  can  make  his  own  decisions 
or  call  for  others  as  he  deems  necessary.  It 
appears  that  the  last  frontier  of  individual 
expression,  action,  and  decision  exists  in  the 
medical  profession. 

A doctor  has  to  make  many  important  de- 
cisions. There  are  many  times  when  a pa- 
tient’s life  or  health  depends  on  the  physi- 
cian’s decision  concerning  treatment  or  medi- 
cation. It  is  this,  these  decisions,  that  make 
the  medical  field  challenging  and  interesting. 

There  is  probably  no  better  feeling  than 
that  of  a doctor  when  he  knows  he  has  suc- 
cessfully performed  an  operation,  or  saved  a 
life,  or  cured  an  extremely  ill  person.  The 
personal  satisfaction  derived  from  doing  one 
or  more  of  these  things  is  very  gratifying. 

94 


The  knowledge  that  one  is  acting  in  the  bene- 
fit of  humanity  in  the  sight  of  God  and  man 
cannot  be  excelled  by  any  other  profession. 

Knowing  that  you  are  needed  and  respect- 
ed in  the  community  by  your  fellow  man  is 
one  thing  for  which  most  people  strive  until 
their  death.  The  doctor  or  doctors  of  the 
community  are  the  citizens  that  most  readily 
find  they  are  needed  and  respected  by  their 
fellow  man.  The  doctor,  in  almost  every  case, 
becomes  one  of  the  pillars  of  the  community. 

He  is  called  upon  not  only  to  give  medical 
advice  but  also  to  solve  personal  and  family 
problems  of  the  local  residents.  His  job  calls 
for,  besides  medical  knowledge,  tact  and  un- 
derstanding. 

Another  branch  of  the  medical  field  that  : 
must  be  covered  is  that  of  the  research  scien- 
tist. The  Salk  Vaccine,  replacements  of  nylon 
for  parts  of  the  heart,  and  the  artificial  kid- 
ney are  all  present  and  in  effective  use  today 
because  of  the  desire  of  men  and  women  to 
advance  the  medical  field.  These  discoveries 
and  vaccines  are  not  usually  made  by  prac- 
ticing physicians.  Research  doctors  and  oth- 
er personnel  today  make  great  strides  in  ad-  i 
vancing  medical  science  because  they  work 
as  a team  in  their  research.  Without  this 
form  of  doctor  the  medical  field  would  be  far  : 
less  advanced  than  it  presently  is.  * 

However,  to  have  practicing  physicians  and 
research  scientists,  there  must  be  teachers  to 
inform  them  of  the  medical  knowledge  and 
technology  known  to  man  at  this  present 
time.  Without  these  teachers  there  would  be 
no  medical  profession,  but  again,  just  a group 
of  charlatans  and  fakers.  The  medical  teach- 
ers, although  they  are  seldom  mentioned  or  ; 
heard  of  by  the  public,  are  those  most  essen- 
tial  to  the  medical  field.  Theirs  should  be 
the  place  of  honor  in  medicine,  for  it  is  they 
who  form  the  backbone  of  the  entire  field. 

In  conclusion,  there  is  nothing  greater  than  ! 
being  a doctor  or  being  in  some  other  branch  | 
of  the  medical  field  and  in  knowing  that  you  ! 

serve  humanity.  It  is  akin  to  the  work  of  ! 

God,  and  all  those  who  go  about  their  prac-  ! 
tice  earnestly  and  sincerely  will  surely  find 
their  place  in  the  Kingdom  of  God. 

t 

J.  M.  A.  ALABAMA  | 


old  Plague — New  Challenge- 


Venereal  Disease 

T.  LEFOY  RICHMAN 


In  the  United  States,  the  nature  of  the  ve- 
nereal disease  hazard  to  the  health  of  the 
public  has  changed  in  recent  years,  and  the 
programs  which  seek  to  eliminate  VD  as  a 
health  hazard  have  changed  to  meet  the  new 
conditions. 

The  teenager  has  come  more  prominently 
into  the  special  VD  problem  group;  sexual 
behavior  is  becoming  more  casual  among 
many  groups;  and  the  prostitute  is  being 
widely  displaced  by  amateurs  as  a spreader 
of  venereal  disease. 

Once  essentially  medical,  the  VD  control 
effort  now  gives  increased  weight  to  educa- 
tion. There  has  emerged  a new  health  pro- 
fession, requiring  specialized  skills  and  apti- 
tudes— VD  Investigation. 

In  the  new  program,  the  private  physician 
is  encouraged  to  play  a major  role,  and  fa- 
cilities are  being  developed  to  assist  him. 

Although  these  changes  have  not  occurred 
within  weeks  or  months,  they  are  sufficiently 
recent  and  their  impact  on  health  and  health 
work  is  sufficiently  significant  to  warrant 


Mr.  Richman  is  Associate  Executive  Director  of 
the  American  Social  Hygiene  Association  and  for- 
mer director  of  public  relations  for  the  United 
States  Public  Health  Service’s  Division  of  Special 
Health  Services.  Among  the  Division’s  programs 
were  venereal  disease  control,  tuberculosis,  chronic 
disease,  heart  disease,  and  environmental  health. 


thoughtful  consideration  of  them  now.  No 
diseases  are  so  essentially  social  as  gonorrhea 
and  syphilis. 

They  are  spread  by  intimate  contact — by 
sexual  intercourse  mainly.  Syphilis  is  some- 
times spread  by  kissing.  Their  route  is  per- 
son to  person;  their  passage  is  direct,  and 
their  presence  is  frequently  unnoticed  until 
they  have  made  themselves  “at  home.” 

The  sexual  contacts  which  spread  venereal 
disease  are  largely  premarital  or  extra-mari- 
tal. Hence,  they  are  illegal  or  immoral  or 
both.  They  require  a clandestine  kind  of 
privacy,  frequently  difficult  to  achieve  (a 
significant  number  of  exposures  to  VD  are 
made  in  automobiles),  and  they  are  associat- 
ed with  feelings  of  guilt,  fear  of  discovery, 
and  often  offsetting  these,  the  excitement  of 
getting  away  with  something. 

Usually,  people  sympathize  with  the  vic- 
tims of  disease.  The  venereal  diseases  are 
among  the  few  exceptions.  Gonorrhea  and 
syphilis  attract  sympathy  only  to  their  “in- 
nocent” victims,  and  these  become  fewer 
each  year.  In  a former  generation,  the  VD 
victim  was  looked  upon  as  a sinner  or  a de- 
serving recipient  of  the  wages  of  sin;  in  ours, 
because  of  widespread  knowledge  of  the  ease 
and  speed  of  cure,  he  is  more  likely  to  be  re- 
garded as  a fool. 

But  even  fools  do  not  wish  to  be  found  out. 
So  the  transmission  of  venereal  disease  is 


AUGUST  I960— VOL.  30,  NO.  2 


95 


THE  ASSOCIATION  FORUM 


given  the  protective  cloak  of  secrecy.  It  is 
also  given,  by  most  of  its  hosts,  the  additional 
protection  of  wishful  thinking.  This  is  par- 
ticularly true  of  syphilis.  The  first  sign  is 
usually  a sore  where  the  germ  has  entered 
the  body.  Even  when  they  notice  such  a sore, 
most  people  do  nothing  about  it.  It  goes  away 
of  its  own  accord.  Following  this  natural  dis- 
appearance, the  “lucky”  victim  heaves  a sigh 
of  relief — “Thank  God,  it  wasn’t  syphilis!” — 
while  the  spirochete  proceeds  to  infiltrate  his 
body. 

Syphilis  and  gonorrhea  have  not  been 
brought  under  control  anywhere  in  the 
world.  In  the  United  States,  where  intensive 
efforts  to  find,  treat,  and  prevent  VD  have 
been  actively  under  way  since  1936,  the  Pub- 
lic Health  Service  estimates  that  about  60,000 
cases  of  syphilis  occur  each  year.  In  1959, 
only  8,178  new,  early  contagious  cases  were 
reported.  Perhaps  1,000,000  or  more  new  cases 
of  gonorrhea  occur  in  the  United  States  each 
year.  In  1959  only  237,318  cases  were  report- 
ed. In  this  discrepancy  between  cases  occur- 
ring and  cases  reported  lies  the  challenge  to 
the  contemporary  health  worker. 

Never  a simple  one,  the  VD  challenge  is 
now  complicated  by  changes  in  public  atti- 
tudes toward  sex  and  sexual  behavior,  by  the 
changing  role  of  the  teenager  in  our  society, 
by  changes  in  clinical  practice  brought  on  by 
penicillin  therapy  and  newer  diagnostic  pro- 
cesses, by  bold  innovations  in  investigation 
and  control,  by  change  in  the  status  and  per- 
formance of  the  prostitute,  and  by  other 
changes  which  we  shall  have  occasion  to  con- 
sider later. 

NO  SENSE  OF  OUTRAGE 

The  Edward  R.  Murrow  broadcast,  January 
19,  1959,  on  “The  Business  of  Sex,”  was  a dis- 
turbing revelation  to  many  people,  involving, 
as  it  did,  testimony  not  only  of  the  use  of 
sex  to  sell  but  also  sex  in  combination  with 
blackmail  and  bribery. 

One  man,  introduced  by  Murrow  as  “presi- 
dent of  a large  international  firm,”  had  said, 
“There  is  absolutely  no  doubt  that  prostitu- 
tion per  se  does  help  business.  This  is  the 


fastest  way  that  I know  of  to  have  an  inti- 
mate relationship  established  with  a buyer. 
It’s  an  experience  which  has  been  shared; 
whether  it’s  together  or  not  makes  no  differ- 
ence. The  point  is,  that  I know  that  the  buy- 
er has  spent  the  night  with  a prostitute  that 
I have  provided.  In  the  second  place,  in  most 
cases  the  buyers  are  married,  with  families. 
It  sort  of  gives  me  a slight  edge;  well,  we  will 
not  call  it  exactly  blackmail,  but  it  is  a sub- 
conscious edge  over  the  buyer.” 

Columbia  Broadcasting  Company  received 
the  usual  surge  of  mail  that  follows  any  sen- 
sational story.  About  20  per  cent  of  the  com- 
munications said  that  the  broadcast  was  in 
bad  taste,  or  expressed  disbelief,  or  in  other 
ways  objected.  The  others  expressed  concern 
and  belief,  congratulated  CBS  on  reporting 
the  facts,  congratulated  Mr.  Murrow  for  his 
forthrightness,  etc.  But  there  was  no  public 
sense  of  outrage.  No  committees  were  or- 
ganized; no  crusades  were  started;  very  few 
pulpits  were  thumped;  and,  in  the  Congress 
of  the  United  States,  where  both  labor  and 
business  practices  were  under  investigation 
at  the  time,  the  CBS  broadcast  caused  hardly 
a ripple. 

THE  SEXUAL  CLIMATE 

This  is  but  one  of  many  indications  that 
the  present-day  attitudes  toward  sex  and  the 
relationships  that  reflect  them  are  undergo- 
ing a profound  change.  There  is  much  sta- 
tistical evidence  to  confirm  this. 

In  1953,  Kinsey,  Pomeroy,  Martin,  and  Geb- 
hard  found  that  26  per  cent  of  their  sample  of 
some  6,000  women  had  had  sex  relations  out- 
side of  marriage  by  the  time  they  were  40, 
and  that  a higher  percentage  of  those  born 
after  1900  had  extra-marital  relations  than 
those  born  before  1900.  Extra-marital  pet- 
ting, too,  they  found,  “seems  to  have  in- 
creased within  recent  years.” 

In  1955  Eugene  Gilbert  reported  in  THIS 
WEEK  that  50  per  cent  of  5,000  teenagers  in- 
terviewed by  his  investigators  considered 
that  it  was  right  for  a couple  “going  steady” 
to  do  “anything  they  want.”  Eighteen  per 
cent  had  placed  the  limit  at  petting;  10  per 


96 


J.  M.  A.  ALABAMA 


THE  ASSOCIATION  FORUM 


cent  at  light  necking;  and  11  per  cent  at  kiss- 
ing. 

In  1958,  Dr.  Jules  Vandow  of  the  New  York 
City  Health  Department,  speculating  on  rea- 
sons for  the  recent  increase  of  VD  in  the  city, 
suggested  “a  greater  breakdown  in  morality 
among  adults,  sifting  down  to  their  children, 
and  that  vanishing  sex  taboos  are  introducing 
greater  promiscuity  with  attending  hazards.” 

In  brief,  modern  living,  with  its  pressures 
to  be  accepted,  to  move  about,  to  consume,  is 
also  characterized  by  increasingly  casual  sex 
relationships  in  large  segments  of  the  popu- 
lation, married  or  unmarried,  and  at  younger 
ages. 

Within  this  climate,  infectious  venereal  dis- 
ease among  persons  under  20  years  of  age  are 
reported  at  the  rate  of  136  cases  per  day — 
which  represents  an  increase,  in  the  past  few 
years,  rather  than  the  hoped-for  decline. 

VD  UNDER  20 

The  American  Social  Health  Association 
estimates  an  annual  VD  infected  population 
in  the  United  States  of  200,000  under  20  years 
of  age.  But  in  any  one  year,  fewer  than  50,- 
000  of  these  are  reported.  Most  of  the  re- 
mainder are  undiscovered.  The  syphilitics 
among  them  may  go  into  early  latency  where 
routine  blood  testing  may  pick  part  of  them 
up,  or  into  late  latency  where  they  may  never 
be  discovered  until  the  onset  of  late  crippling 
manifestations.  Those  with  gonorrhea  may 
become  sterile  or  develop  gonorrheal  arth- 
ritis. A few  will  have  worried  themselves 
into  a doctor’s  office  (usually  a doctor  not 
known  to  family  or  friends),  and  will  have 
received  treatment.  Some,  of  course,  may 
suffer  no  late  complications,  even  though 
they  go  untreated.  But  the  risk  they  take  is 
great. 

All  in  all,  22  states,  1 territory,  and  31  cities 
reported  rises  in  VD  among  the  15-19  age 
group  in  1958,  and  12  states,  1 territory,  and 
13  cities  reported  a rise  in  the  10-14  age  group. 

Today’s  increase  in  venereal  disease  among 
young  people  should  not  be  considered  as  un- 
related to  other  symptoms  of  social  malad- 
justment. It  should  be  regarded  as  one  of 

AUGUST  I960— VOL.  30,  NO.  2 


the  elements  of  a pattern  which  includes  in- 
creasing illegitimate  parenthood  at  younger 
ages,  increasing  mental  health  problems,  and 
increasing  juvenile  offenses. 

Juvenile  problems,  including  VD,  are  seen 
more  and  more  as  symptoms  of  social  illness 
which  may  not  be  approached  as  isolated 
problems  unrelated  in  their  causes  or  need 
for  service  and  corrective  program. 

A recent  study.  Interaction  of  “V.D.”  and 
Other  Social  Problems,  shows  that  in  New 
York  City,  97  of  the  city’s  352  health  areas, 
with  27  per  cent  of  the  city’s  population,  are 
responsible  for: 

51'/  of  all  juvenile  offenses 

73'/)  of  all  Aid  to  Dependent  Children 

45'/  of  all  infant  mortality 

71'/  of  all  venereal  disease 

41%  of  all  psychiatric  clinic  cases 

THE  UNDER-20  SEX  SELL 

The  teenage  group  is  defined  by  the  Bu- 
reau of  the  Census  as  boys  and  girls  13  to  19 
years  of  age.  There  are  about  17  million  of 
them;  by  1965,  there  will  be  24  million.  The 
present  teenage  generation  is  estimated  to 
have  some  91/2  billion  dollars  to  spend,  inde- 
pendent of  parental  guidance.  They  have, 
therefore,  attracted  the  attention  and  careful 
study  of  the  advertising  profession.  An  at- 
tractive brochure  distributed  to  advertisers 
declares;  “Because  of  girls’  emotionalism  at 
this  age,  a romantic  approach  often  may  be 
successful.  Teens  like  to  view  photographs 
showing  young  people  wearing,  using,  or  con- 
suming a product  or  service.  The  pressure 
they  exert  (on  family  spending)  is  very 
great.  And  they  are  consistently  being  stim- 
ulated by  movies  and  TV  to  want  more.” 
Food,  clothing,  automobiles,  cigarettes, 
beer,  sports  equipment,  vacations,  travel,  cos- 
metics, entertainment,  foundation  garments, 
records,  soft  drinks,  and  many  other  products 
are  sold  to  and  through  teenagers  by  means 
of  TV,  movies,  newspapers,  magazines,  comic 
books,  and  billboards. 

HOW  OLD  IS  THE  VD  PATIENT? 

The  teenage  market  is  a specialty,  requiring 
treatment  with  themes  delicately  tuned  to 

97 


THE  ASSOCIATION  FORUM 


the  adolescent  ear  and  group  conscience.  Sex 
is,  of  course,  a prominent  theme — handled  for 
the  most  part  with  caution,  but  effectively. 

Love  smiles  over  the  snow-white  shoulder 
if  the  underarm  is  free  of  odor. 

“How  to  make  him  take  you  to  the  prom” 
sells  perfume. 

The  sex  sell  to  teenagers  is  not  always 
brash,  is  not  always  loud.  It  is  often  in  the 
best  of  taste.  Its  effectiveness  lies  in  its  un- 
relenting pressure  toward  conformity.  It  is 
least  restrained  and  most  obvious  in  the  flam- 
boyantly erotic  record  album  and  paperbook 
covers;  it  is  most  restrained  in  the  slick  maga- 
zine ads,  carefully  tuned  to  their  candid  dis- 
cussion-type teen-sex  articles.  But  it  never 
ceases;  in  all  the  avenues  of  appeal  it  is  pre- 
dominant. The  sex  sell  may  not  bring  about 
a more  sexually  casual  teenage  society,  but  it 
certainly  never  permits  the  advantages  of 
being  sexually  desirable  to  be  disregarded  by 
boys  or  girls. 

SEXUAL  PROMISCUITY  AND  VD 

The  argument  that  sexual  promiscuity 
need  not  be  a factor  in  the  spread  of  venereal 
disease  is  justified.  A group  could  remain 
sexually  promiscuous  indefinitely  without 
VD  infection  if  the  group  were  never  contam- 
inated from  outside.  But  in  our  highly  mo- 
bile population,  the  possibility  of  any  promis- 
cuous group  protecting  itself  from  VD  is  re- 
mote. Penicillin  is  effective,  inexpensive, 
widely  available,  easy  to  administer,  and 
even  offers  a measure  of  prophylactic  protec- 
tion. Nevertheless,  it  has  not  “stopped”  gon- 
orrhea and  syphilis  in  the  population,  even 
though  since  its  earliest  use,  it  has  been  as- 
sisted (with  one  notable  lapse  which  we  shall 
note  later)  by  a hard-hitting,  persistent  case- 
finding effort. 

Indeed,  one  of  the  largest  syphilis  epidem- 
ics ever  recorded  occurred  in  a southwestern 
state  in  1957-58.  Of  the  625  persons  involved 
(sexually  linked  whether  or  not  infected), 
220  were  teenagers  and  younger  children — 
from  infancy  to  age  19.  Among  them  were 
two  syphilitic  stillbirths  and  one  congenital 
syphilitic  infant. 


Thus,  with  the  availability  of  an  almost 
miraculous  “cure”  for  venereal  disease, 
changes  in  public  attitude  toward  sex  and 
sexual  behavior  have  brought  about  also  an 
increasingly  favorable  environment  for  the 
spread  of  venereal  disease.  And  the  health 
worker,  in  attempting  to  be  effective  in  this 
new  environment,  has  been  forced  to  inno- 
vate and  experiment  with  the  tools  he  works 
with. 

DECADE  OF  PROGRESS 

Before  1942,  the  minimum  course  of  treat- 
ment for  syphilis  consisted  of  alternate  injec- 
tions of  arsenic  and  bismuth,  one  a week  for 
72  weeks.  The  most  difficult  problem  in  con- 
trol was  holding  patients  to  such  a long  treat- 
ment, especially  since  their  symptoms  disap- 
peared in  a matter  of  days,  and  they  felt  all 
right  as  soon  as  treatment  began. 

In  1942,  the  Public  Health  Service  set  up 
specialized  VD  hospitals  called  Rapid  Treat- 
ment Centers.  These  were  designed  to  re- 
duce treatment  time  to  a matter  of  days  by 
feeding  arsenic  into  the  patients’  veins  in  a 
continuous  (around  the  clock)  drip  method 
until  the  prescribed  dosage  had  been  taken. 
The  element  of  risk  was  high  and  the  admin- 
istration of  the  drug  required  great  care,  but 
there  was  a war  on,  and  VD  was  considered 
to  be  a hindrance  to  the  war  effort. 

Penicillin  revolutionized  the  management 
of  venereal  disease  within  a year.  In  October 
1943,  Dr.  John  Mahoney  read  before  the  An- 
nual Meeting  of  the  American  Public  Health 
Association  a report  of  the  successful  use  of 
penicillin  in  the  treatment  of  syphilis  in  four 
male  patients  at  Staten  Island.  He  concluded 
his  report  with  these  words: 

Should  more  extensive  and  prolonged  ex- 
perience confirm  the  impression  which  is 
to  be  gained  from  the  pilot  study,  a rebuild- 
ing of  the  structure  of  syphilis  therapy  may 
become  necessary. 

Even  Dr.  Mahoney  must  have  been  amazed 
at  the  speed  with  which  this  rebuilding  took 
place.  Penicillin  was  tried  in  the  Rapid 
Treatment  Centers  immediately.  In  1945,  63 
Centers  treated  32,000  patients  with  infec- 


98 


J.  M.  A.  ALABAMA 


THE  ASSOCIATION  FORUM 


tious  syphilis.  In  1946,  the  RTC’s  treated 
120,000  syphilis  patients  and  in  1947  (the 
peak  year)  185,000  patients.  Treatment  time 
had  been  cut  to  a matter  of  days,  and  sudden- 
ly the  VD  control  problem  had  shifted  from 
caseholding  to  casefinding.  During  this  time, 
the  problem  of  too  speedy  elimination  of 
penicillin  from  body  tissue  was  being  solved 
by  a variety  of  absorption-delaying  penicil- 
lin preparations.  The  diagnostic  tools  were 
similarly  improved. 

The  rapid  progress  in  diagnosis  and  treat- 
ment brought  about  an  equally  speedy  shift 
in  management.  Patients  were  kept  in  the 
Rapid  Treatment  Centers  until  the  treatment 
was  completed.  As  long  as  treatment  required 
several  days  or  weeks,  the  Centers  could  be 
operated  economically;  but  by  1951  the  new- 
er penicillin  preparations  were  beginning  to 
suggest  single  session  treatment.  Massive 
dosages  that  could  be  administered  in  a sin- 
gle visit  to  doctor  or  clinic,  maintaining  high 
concentration  of  penicillin  in  the  blood  for 
days,  and  with  no  need  for  continuous  obser- 
vation of  the  patient,  obviously  eliminated 
the  need  for  hospital  care. 

By  1953,  the  Rapid  Treatment  Centers  were 
being  displaced  by  out-patient  centers,  and 
Surgeon  General  Leonard  A.  Scheele  was 
able  to  say,  “Now  every  private  physician  can 
be  an  efficient  venereal  disease  control  offi- 
cer, giving  ambulatory  treatment  to  patients 
in  his  office.”  By  1954,  General  Scheele’s  po- 
sition was  made  doubly  secure  when  a single 
injection  of  benzathine  penicillin  G became 
the  established  treatment  for  early  syphilis. 
This  preparation  maintains  a spirochete-kill- 
ing level  of  penicillin  in  the  blood  for  several 
weeks. 

THE  VD  INVESTIGATOR 

Along  the  way,  in  the  decade  1944-54,  when 
such  important  advances  were  being  made  in 
the  diagnosis  and  treatment  of  the  venereal 
diseases,  there  came  into  being  a new  kind  of 
health  worker  and  a new  kind  of  health  work 
— the  venereal  disease  investigator  and  VD 
casefinding. 


They  did  not  emerge  suddenly,  the  new 
worker  and  the  new  work.  They  developed 
rather  from  personnel  employed  for  other 
purposes  and  out  of  other  efforts.  These  in- 
dividuals were  not  among  the  established 
public  health  professionals;  their  service  was 
a response  to  a new  need. 

The  investigator  had  to  be  able  to  talk  to 
the  sex  contacts  of  patients  convincingly 
wherever  they  chose  to  talk.  Bars,  taverns, 
bawdy  houses,  street  corners,  alleys — most 
investigations  started  and  many  ended  in 
such  places.  It  was  clearly  not  work  for  tim- 
id souls.  Gradually,  young  men  selected 
chiefly  for  their  interest  and  lack  of  timidity 
tried  their  hands  at  interview  and  investiga- 
tion. And  they  did  well. 

But  by  1946,  they  had  come  to  realize  they 
were  not  doing  well  enough.  Until  then,  the 
interview  for  the  names  and  addresses  of  sex 
partners  was  a search  for  the  “source  of  your 
infection.  Where  did  you  get  it?”  The  in- 
terviewers were  inclined  to  stop  when  they 
got  a name.  They  conceived  their  problem 
to  be  persuading  the  patient  to  give  them  the 
“real  source”  of  his  or  her  infection.  This  the 
patient  seldom  knew,  and  often  the  name 
proved  to  be  false. 

Alfred  Kinsey  was  about  to  publish  Sexual 
Behavior  in  the  Human  Male.  He  had  been 
addressing  Venereal  Disease  Control  Semi- 
nars where  health  workers  were  given  a 
chance  to  discuss  with  him  the  data  he  was 
processing.  It  was  suggested  that  Dr.  Kinsey 
review  interview  techniques  then  being  em- 
ployed in  VD  casefinding.  Out  of  this  review 
and  discussion  with  public  health  personnel 
came  two  recommendations:  (1)  Keep  talk- 
ing; the  patient  very  likely  has  many  sex 
partners.  (2)  Narrow  the  interview  to  a 
single  purpose — getting  reliable  information. 
Don’t  try  to  explain  to  the  patient  how  the 
darkfield  microscope  works.  Just  concern 
yourself  with  names  and  addresses,  and  dis- 
cuss only  what  is  necessary  to  get  the  infor- 
mation you  must  have. 

From  then  on,  VD  Control  was  a new  pro- 
gram, and  the  Public  Health  Service  had  ac- 
quired a new  profession — VD  investigation. 


AUGUST  I960— VOL.  30,  NO.  2 


99 


THE  ASSOCIATION  FORUM 


In  1947,  the  first  training  school  for  VD  in- 
vestigators was  opened  in  Washington,  D.  C. 
Candidates  came  from  Army,  Navy,  Air 
Force,  and  the  Public  Health  Service.  The 
school  provided  interview  experience  with 
real  patients;  it  offered  group  discussion  pos- 
sibilities under  the  guidance  of  a skilled  in- 
terviewer. Out  of  such  discussion  and  ex- 
perience, the  school  was  able  to  develop  the 
fundamentals  of  a specialized  technique. 

The  techniques  employed  at  the  school  pro- 
duced results.  Trainees  were  able  to  secure, 
in  many  instances,  twice  as  many  names  of 
sex  contacts  per  interview  as  formerly.  Ad- 
ditional schools  were  set  up  in  Norfolk;  De- 
troit; Alto,  Georgia;  Atlanta;  San  Antonio; 
New  York;  and  Los  Angeles.  Besides  these, 
some  states  and  cities  ran  training  sessions  on 
their  own.  A small-scale  but  wide-ranging 
recruitment  service  was  developed  which 
sought  out  and  found  young  college  graduates 
inclined  toward  public  service  and  challenge. 
These  were  given  short,  intensive  courses  in 
interview-investigation,  assigned  to  state  or 
city  health  departments  to  work  under  ex- 
perienced men,  and  encouraged  to  grow  in 
their  jobs. 

By  the  middle  of  1953,  the  VD  situation  was 
as  follows; 

There  had  been  substantial  improvement 
in  the  treatment  of  both  gonorrhea  and 
syphilis.  The  newer  penicillin  schedules 
had  definitely  established  out-patient 
treatment.  Diagnostic  tools  had  been 
sharpened  and  improved. 

Though  still  fallible,  they  were  reliable  in 
the  detection  of  disease  when  used  by 
adequately  trained  personnel.  The  core 
of  the  control  activity  was  case  finding, 
and  the  interview-investigator  had  estab- 
lished himself  as  indispensable  in  that 
function. 

Through  federal  project  grants  and  as- 
signment of  federal  personnel  to  states, 
there  had  been  achieved  a uniformity 
of  VD  program  throughout  the  country 
which  permitted  planning  on  a national 
scale. 


Reported  cases  of  gonorrhea  had  fallen  con- 
sistently and  sharply  for  seven  years, 
syphilis  for  ten.  In  1947,  the  peak  year 
for  gonorrhea,  400,639  cases  had  been  re- 
ported; six  years  later,  243,857.  In  1943, 
the  peak  year  for  syphilis,  575,593  cases 
had  been  reported;  ten  years  later,  156- 
099. 

POLITICAL  ECONOMY 

The  federal  budget  for  1953  provided  $5,- 
000,000  in  federal  funds  for  the  control  of 
venereal  disease,  a reduction  from  nearly 
$10,000,000  the  previous  year.  This  was  re- 
garded by  responsible  health  authorities  as: 
a drastic  reduction.  Nevertheless,  the  budget 
makers  in  1954  called  for  still  further  reduc- 
tions to  $2,300,000.  The  implications  were 
that  VD  had  been  so  reduced  as  a health 
hazard  that  funds  should  now  be  directed 
toward  other  and  more  urgent  health  prob- 
lems. Some  health  officers  shared  this  view. 
But  the  results  were  unfortunate.  Although 
$700,000  was  restored  to  the  federal  VD 
budget  for  a total  of  $3,000,000  for  fiscal  1954, 
a “dying  program”  psychology  had  been 
established.  States,  following  the  federal  ex- 
ample, began  to  withdraw  personnel  from 
VD  for  assignment  to  health  programs 
then  just  emerging  into  public  health  promi- 
nence— cancer,  heart,  chronic  diseases,  care 
of  the  aging,  air  pollution,  and  so  on.  With 
limited  federal  funds  for  grants,  the  unifying 
influence  of  the  federal  government  on  state 
and  local  planning  began  to  diminish. 

The  American  Social  Hygiene  Association 
was  highly  skeptical.  It  alerted  the  American 
Venereal  Disease  Association  and  the  Asso- 
ciation of  State  and  Territorial  Health  Of- 
ficers. The  three  groups  jointly  sponsored  a 
national  survey  to  determine  the  facts.  Their 
first  survey,  published  in  February  1954,  was 
a forceful  and  carefully  documented  dissent 
to  the  proposition  that  VD  was  no  longer  a 
serious  public  health  hazard.  The  three  as- 
sociations have  published  a joint  statement 
each  year  since  1954,  and  their  recommenda- 
tions have  been  presented  to  the  public  and 
its  leaders  in  health  and  government. 


100 


J.  M.  A.  ALABAMA 


THE  ASSOCIATION  FORUM 


THE  NEW  PROBLEM 

The  next  five  years  witnessed  a steady  re- 
building of  the  national  VD  control  program. 
In  this  rebuilding  process,  state,  local  and 
federal  VD  workers  have  been  forced  to 
stretch  their  budgets  over  flexible  program 
structures.  At  the  insistence  of  professional 
and  voluntary  organizations,  federal  appro- 
priations have  been  slowly  built  up  to  $5,- 
400,000.  Professional  staff  is  being  carefully 
replaced.  And  with  this  rebuilding  and  re- 
placement, there  is  being  fashioned  a new 
program  to  meet  a surprising  new  problem. 

It  is  not  easy  to  define  the  new  problem. 
State  health  department  officials  in  almost 
half  of  our  states  do  not  believe  that  syphilis 
case  reporting  is  complete  enough  to  provide 
a reliable  indication  of  the  syphilis  attack 
rate  or  the  backlog  of  latent  syphilis  cases. 
Furthermore,  health  officals  in  one-third  of 
the  cities  of  more  than  100,000  population  in- 
dicate that  the  prevalence  of  syphilis  is  seri- 
ously under-reported.  What  about  the  num- 
ber of  cases  that  are  reported?  How  many 
cases  are  treated  by  physicians  and  not  re- 
ported? How  many  cases  are  never  suspected 
and  progress  into  latency  undetected?  In  how 
many  cases  are  the  symptoms  masked  by  pen- 
icillin used  to  treat  other  ailments?  One  thing 
is  certain.  Most  cases  of  reported  syphilis  in 
the  United  States  are  diagnosed  late.  In  1959, 
of  119,981  cases  of  syphilis  reported  94,211 
were  reported  in  the  late  stages  (4  to  30  years 
after  infection) , 17,592  in  the  early  latent 
stages,  and  only  8,178  in  the  early  infectious 
stage. 

Characteristic  of  the  new  problem  are  the 
younger  age  groups  involved.  The  Public 
Health  Service,  in  order  better  to  reach  the 
increasing  numbers  of  teenage  VD  patients 
through  interview,  has  called  on  the  Ameri- 
can Social  Health  Association  to  undertake 
a study  of  teenagers  in  New  York  City  VD 
clinics.  One  of  the  purposes  of  the  study  is 
to  describe  these  young  persons  in  terms  that 
will  be  helpful  to  interviewers  trying  to  get 
contact  information  from  them  and  to  edu- 
cators trying  to  reach  them  before  they  be- 


come involved  in  conduct  leading  to  venereal 
disease. 

The  new  problem  is  shifting  our  attention 
from  exclusive  concern  with  the  biology  of 
sex  and  the  medical  aspects  of  VD  control  to 
the  question  of  sexual  behavior  and  the 
broad,  social  aspects  of  control.  It  has  be- 
come apparent  that  drugs  don’t  stop  VD  in 
the  population.  Indeed  it  is  pertinent  to  note 
that  communicable  disease  has  rarely  been 
eradicated  with  treatment  alone,  and  that 
eradication  without  some  form  of  immuniza- 
tion is  least  likely  in  the  case  of  these  most 
social  of  diseases. 

THE  PROSTITUTE  AS  A VD  CARRIER 

We  must  also,  in  considering  the  new  VD 
problem,  take  note  of  the  changing  role  of 
the  prostitute  in  American  Society.  Prior  to 
penicillin,  anti-prostitution  activity  was  a 
basic  part  of  the  VD  control  effort.  The 
prostitute  could  serve  a large  number  of  men 
in  a single  evening  and  spread  her  infection 
through  them  to  wives,  unborn  infants  and 
others.  Even  then,  some  authorities  contend- 
ed that  the  prostitute,  because  she  had  to 
keep  fit  to  keep  working,  took  care  (soap 
and  water  kill  both  the  gonococcus  and  the 
spirochete  before  they  penetrate  membrane 
or  skin)  not  to  become  a victim  and  thus  a 
carrier  of  VD.  This  may  have  been  true  of 
some  prostitutes,  but  for  the  most  part  the 
prostitute  was  a VD  carrier  and  an  object 
of  real  concern  to  health  officers. 

After  penicillin,  it  became  much  easier  for 
the  prostitute  to  protect  herself  and,  to  some 
extent,  her  customer — especially  since  the 
absorption-delaying  preparations  could  ren- 
der her  prophylactically  secure  for  days  and 
even  weeks. 

She  had,  however,  become  less  of  a VD 
problem  for  quite  other  reasons  than  penicil- 
lin. She  had  become  a casualty  of  World  War 
II.  Traditionally,  prostitution  has  flourished 
in  time  of  war  and  around  military  camps. 
The  early  months  of  World  War  11  were  no 
exception.  But  as  the  war  effort  began  to 
build,  two  disturbing  things  happened  to  the 


AUGUST  I960— VOL.  30,  NO.  2 


101 


THE  ASSOCIATION  FORUM 


exploiters  of  the  prostitute:  they  lost  many 
of  their  girls  to  the  war  effort — a girl  could 
get  respect  and  be  financially  independent  as 
a riveter — and  those  they  didn’t  lose  were  so 
harassed  by  federal,  state,  county  and  local 
police  that  keeping  them  at  work  cost  more 
than  the  returns. 

In  addition,  war  separations,  war  travel  and 
transiency,  war  rootlessness,  war  domination 
of  personal  goals — these  contributed  to  an 
era  of  promiscuity  which  put  the  prostitute, 
to  a considerable  extent,  out  of  demand. 
Hence  she  became  replaced  as  a VD  carrier 
by  the  amateur,  the  pickup,  the  promiscuous 
working  girl  who  wanted  a good  time  or 
status  or  some  show  of  affection.  The  prosti- 
tute became  a smaller  and  smaller  factor  in 
the  VD  contact  reports,  and  she  has  not  yet 
returned  as  a serious  VD  problem. 

American  Social  Hygiene  surveys  show 
that  among  cities  under  continuous  surveil- 
lance between  1940  and  1959,  the  percentage 
of  surv'eys  reporting  no  flagrant  prostitution 
(rated  A)  mounted  steadily,  whereas  the  per- 
centage of  surveys  reporting  open  solicitation 
by  prostitutes  on  streets  and  in  public  places 
(rated  D)  declined,  not  so  steadily  but  sub- 
stantially. 

The  call  girl,  who  has  grown  in  status  in 
recent  years,  has  not  shown  herself  to  be  a 
serious  VD  problem.  She  is  highly  paid  and 
can  afford  penicillin  prophylaxis,  which  her 
customers  presumably  demand. 

American  Social  Hygiene  studies  on  prosti- 
tution continue  as  a safeguard  against  con- 
ditions which  are  a hazard,  not  only  to  per- 
sonal health  but  to  family  life  and  to  healthy 
municipal  government.  Although  conditions 
vary  from  town  to  town,  prostitution,  wheth- 
er at  call  girl,  streetwalker,  or  any  level  in 
between,  reflects  naive  or  corrupt  govern- 
ment. Prostitution  is  illegal  and,  in  order  to 
thrive,  must  have  protection.  It  needs  ano- 
nymity and  its  practitioners  must  be  able  to 
keep  moving.  This  means  not  only  protection 
but  protection  that  can  be  relied  upon. 


ON  THE  ROAD 

The  replacement  of  the  prostitute  as  a VD 
carrier  by  the  pickup  is  in  line  with  the  gen- 
eral tendency  of  VD  to  become  a problem  of 
transiency.  Where  surveys  have  been  made 
of  VD  among  transient  workers,  the  percent- 
ages infected  are  uniformity  high: 

In  Arizona,  about  9 per  cent  of  the  transi- 
ent labor  force  were  found  to  be  infected 
with  syphilis.  A similar  percentage  was 
established  in  a study  of  70,000  migrant 
farm  workers  in  California.  Tobacco 
workers  in  Connecticut  and  Kentucky, 
automobile  plant  employees  in  Michigan, 
truck  garden,  cotton,  fruit  and  other  crop 
workers  along  both  seaboards  and  in  the 
South,  transient  Indian  populations  in 
Oregon,  New  Mexico  and  Arizona,  crews 
from  out  of  the  state  installing  natural 
gas  pipelines  in  Spokane,  Canadian  and 
Mexican  harvest  hands  in  Washington — 
all  contribute  to  the  VD  problem  in  their 
host  states. 

THE  NEW  PROGRAM— THE  PRIVATE  PHYSICIAN 

Although  the  private  physician  has  always 
figured  prominently  in  VD-control  thinking, 
he  has  never  really  become  part  of  the  control 
team  in  any  significant,  nationwide  effort. 
The  new  program,  based  on  successful  ex- 
periments in  Georgia  and  South  Carolina  and 
on  the  fairly  certain  knowledge  that  the  pri- 
vate physician  reports  not  more  than  one  out 
of  four  of  the  early  infectious  cases  he  treats, 
has  two  major  objectives  for  private  physi- 
cian participation:  an  increase  in  reporting 
of  his  cases  from  the  present  25  per  cent  to 
100  per  cent  and  an  increase  in  interviews  of 
his  patients  from  the  present  25  per  cent  to 
100  per  cent  of  those  reported. 

In  order  to  do  this,  health  departments  are 
developing  a reporting  form  that  requires 
only  the  time  to  check  boxes  and  sign  a name. 
Physicians  are  busy,  and  they  will  not  wish  to 
spend  time  sorting  through  involved  report 
forms.  Health  Departments  must  also  pro- 
vide tactful,  competent  interview  service  to 
the  physician  when  he  requests  it. 


102 


J.  M.  A.  ALABAMA 


THE  ASSOCIATION  FORUM 


In  the  health  department  clinics,  a major 
goal  must  be  improved  interviewing  to  bring 
to  treatment  a greater  proportion  of  persons 
with  early  infectious  syphilis  for  each  early 
infectious  patient  interviewed.  This  propor- 
tion is  called  the  “lesion-to-lesion”  index,  and 
it  is  presently  .29 — a little  over  one  early  in- 
fectious case  brought  to  treatment  from  every 
jour  patients  with  early  infections  inter- 
viewed. Since  1952,  the  index  has  risen  slow- 
ly but  consistently  from  .20.  With  present 
control  techniques,  this  index  must  rise  to 
near  .70  to  effect  a decisive  increase  in  the 
number  of  early  infectious  cases  reported. 

CLUSTER  TESTING 

One  of  the  devices  for  increasing  the  yield 
of  early  infectious  cases  is  what  has  been 
called  “cluster  testing.”  This  is  a bold  inno- 
vation, whose  logic  rests  on  two  premises: 
first,  that  the  straight  line  “chain-of-infec- 
tion”  concept  of  casefinding,  wherein  only 
the  sexual  partners  of  actual  syphilis  patients 
are  interviewed,  is  not  likely  to  uncover 
separate  but  socially  related  chains  of  infec- 
tion within  the  same  sexual  community;  and 
second,  that  syphilis  patients  are  likely  to 
know  potential  syphilis  patients  in  their  com- 
munity even  though  they  may  have  no  sexual 
linkage  with  them. 

In  cluster  testing,  the  patient  is  interviewed 
for  his  sexual  partners  and  then  for  individ- 
uals from  among  his  friends  and  acquaint- 
ances who,  he  thinks,  may  be  having  approxi- 
mately the  same  sex  experiences  as  himself. 

The  results  thus  far  have  been  more  than 
hoped  for.  Where  cluster  testing  programs 
have  been  tried,  the  proportion  of  early  in- 
fectious syphilis  cases  brought  to  treatment 
has  increased  substantially.  In  one  instance, 
a cluster  interview  of  285  patients  with  early 
infectious  syphilis  brought  to  treatment  an 
additional  153  early  infectious  cases,  82  cases 
in  latent  stages,  and  115  cases  that  had  been 
treated  inadequately. 

WORK  FAST 

In  the  new  program,  speed  has  come  to 
have  special  significance.  The  time  it  takes 


the  investigator  to  bring  a contact  to  diagnose 
or  to  notify  another  health  jurisdiction  is 
critical.  The  interview  is  aimed  at  getting 
the  infected  sex  partners  to  diagnosis.  The 
speed  of  investigation  determines  whether 
there  are  few  or  many  exposures  to  other  un- 
known contacts.  In  the  case  of  transients, 
speed  may  be  the  difference  between  finding 
and  not  finding  the  contact.  For  that  reason 
every  case  of  infectious  syphilis  is  regarded 
as  a medical  emergency  which  could  lead  to 
an  epidemic.  Investigations  are  distributed 
so  that  they  are  not  permitted  to  pile  up.  It 
is  better  to  have  an  investigator  waiting  for 
an  assignment  than  an  assignment  of  such 
critical  urgency  waiting  for  an  investigator. 

SOME  THOUGHTS  ON  EDUCATION 

Venereal  disease,  the  most  social  of  the  ills 
of  man,  is  also  the  least  confined,  the  least 
manifest,  the  least  likely  ever  to  be  static.  For 
this  reason  more  than  any  other,  the  educa- 
tion that  would  prevent  venereal  disease 
must  be  broad-gauge  and  must  be  applied 
early  in  the  life  of  every  youngster. 

Our  research  in  adolescent  sex  behavior 
suggests  that  the  promiscuity  which  almost 
always  leads  to  VD  is  much  less  likely  to  oc- 
cur in  children  who  feel  secure  in  their  family 
and  social  relationships  and  who  have  clear- 
cut  goals  in  life. 

The  famdly  is  the  earliest  and  ablest  (for 
good  or  ill)  teaching  force  in  society.  Edu- 
cation for  the  prevention  of  VD  begins  there, 
in  situations  which  teach  children  to  trust 
themselves,  to  get  satisfactions  out  of  person- 
al relationships,  to  work  productively,  to  de- 
velop respect  for  self,  peers,  and  parents. 

Granted  that  a certain  percentage  of  Amer- 
ican families  do  not  teach  children  trust  or 
happiness  in  personal  relationships,  and  that 
a certain  percentage  of  American  youngsters 
have,  in  effect,  no  recognizable  family  affilia- 
tion worth  the  name;  and  granted  that  it  is 
among  these  young  people  we  find  the  bulk 
of  our  teenage  VD  patients.  Can  we  afford  to 
wait  for  families  to  be  repaired  or  recon- 


AUGUST  I960— VOL.  30,  NO.  2 


103 


THE  ASSOCIATION  FORUM 


structed  or,  indeed,  created,  to  solve  our  teen- 
age VD  problems? 

Obviously  not. 

The  community  is  the  larger  family.  Com- 
munities have  a fair  amount  of  control  over 
youngsters — if  they  choose  to  exercise  it. 
School  and  church  programs  can  be  strength- 
ened to  provide  the  best  in  recreation  and  so- 
cial service.  And  all  the  youth-serving  agen- 
cies can  be  part  of  a unified  community  ef- 
fort— if  the  community  wishes  it! 

But  even  this  will  not  suffice  for  VD  edu- 
cation unless  the  community  can  determine 
what  its  approach  to  sex  education  shall  be. 
In  school,  venereal  disease  can  be  discussed 
(but  usually  isn’t)  anywhere  along  the  way — 
in  social  studies,  history,  physiology,  biology, 
even  chemistry.  In  these  discussions,  how- 
ever, it  must  be  possible  to  relate  venereal 
disease  to  sex  without  embarrassment  and 
without  fear  on  the  part  of  the  teacher  that 


parents  will  object  and  school  authorities 
panic. 

Actually,  studies  by  the  American  Social 
Hygiene  Association  suggest  that  youngsters 
wish  to  talk  about  their  most  intimate  prob- 
lems (singly  or  in  groups)  to  adults  who  can 
listen.  Teenagers  find  less  difficulty  in  dis- 
cussing sex  candidly  than  do  their  parents. 
But  laws  which  forbid  the  teaching  of  sex, 
parents  whose  unease  with  the  subject  pre- 
vent their  teaching  it  to  their  children  or 
permitting  others  to,  and  the  common  double 
standard  which  says  publicly,  “Sex  is  dirty!” 
and  privately,  “but  nice!” — these  defeat  even 
the  most  determined  efforts  to  develop 
wholesome  attitudes  toward  sex. 

VD  may  not  be  controlled  in  our  time.  It 
certainly  will  not  be  if  we  fail  to  recognize  it 
for  what  it  is — a serious  symptom  of  family 
and  community  failure.  Its  control  depends 
upon  vigorous  prosecution  of  all  the  elements 
of  the  present  program — diagnosis,  treat- 
ment, casefinding,  plus  sane  sex  education. 


104 


J.  M.  A.  ALABAMA 


New  Victory  Over  Smallpox 


The  cow  and  the  chicken  are  combining  to 
protect  the  public  against  an  ancient  enemy, 
smallpox. 

The  disease,  which  in  the  18th  century 
alone  killed  60  million  Europeans,  has  been 
tamed  by  infecting  man  with  a disease  found 
in  cows  called  cowpox.  By  the  process 
known  as  vaccination  a small  amount  of  the 
cowpox  virus  is  transmitted  to  man,  causing 
only  a minor  skin  reaction  while  actually  im- 
munizing against  smallpox,  its  deadly  cousin. 
The  word  “vaccination”  itself  is  derived  from 
the  Latin  name  for  cow. 

For  many  years  the  smallpox  vaccine  was 
produced  by  collecting  the  cowpox  virus  from 
calves.  But  the  method  was  slow  and  fear  of 
outside  contaminants  reduced  the  production 
season  to  the  winter  months  when  dust  and 
insects  were  at  a minimum.  If  an  epidemic 
had  occurred,  inability  to  produce  the  vaccine 
on  a year-round  basis  could  have  seriously 


impaired  mass  vaccination  programs.  In  ad- 
dition, the  calf  grown  vaccine  often  caused 
skin  reactions  which  led  to  scarring. 

Fortunately,  scientists  at  Lederle  Labora- 
tories have  developed  a new  method  to  mass! 
produce  the  vaccine.  And  this  is  where  the 
chicken  enters  the  picture.  By  growing  the 
cowpox  virus  in  chicken  eggs,  they  have  not 
only  speeded  production  of  the  vaccine  but 
are  also  able  to  produce  it  at  any  time  of  the 
year.  It  has  been  found  that  the  new  method 
reduces  the  possibility  of  scarring  or  reac- 
tions due  to  the  vaccine. 

Although  routine  vaccination  has  virtually 
eliminated  the  disease  as  a problem  in  the 
United  States,  other  parts  of  the  world  have 
not  been  so  fortunate.  For  instance,  among 
our  neighbors  in  Latin  America  there  have 
been  more  than  100,000  cases  of  smallpox  and 
16,000  deaths  due  to  the  disease  since  1949,  ac- 
cording to  the  Pan  American  Health  Organi- 


AUGUST  I960— VOL.  30,  NO.  2 


105 


THE  ASSOCIATION  FORUM 


zation.  In  1958  alone  247,000  cases  of  small- 
pox were  reported  throughout  the  world — 
88  per  cent  of  them  in  India  and  Pakistan. 
In  January  1960,  Moscow  reported  a small- 
pox outbreak  and  began  immunizing  its  five 
million  inhabitants. 

The  relatively  high  incidence  of  smallpox 
outside  the  U.  S.  is  the  reason  all  tourists 
leaving  this  country  for  abroad  must  show 
proof  of  recent  vaccination. 

Even  with  almost  universal  smallpox  vac- 
cination in  this  country,  we  have  had  some 
scares  recently.  In  1946  there  were  eight 
deaths  among  28  smallpox  cases  on  the  West 
Coast,  and  New  York  City  had  two  deaths 
and  nine  cases  in  1947.  Six  million  people 
were  vaccinated  in  New  York  during  that 
outbreak,  and  the  nation’s  vaccine  supply  was 
seriously  depleted.  With  the  new  method  of 
growing  the  vaccine  in  eggs,  additional  pro- 
duction can  now  be  initiated  at  any  time. 

Mankind  has  suffered  the  ravages  of  small- 
pox for  at  least  three  thousand  years.  The 
earliest  written  account  of  the  disease  con- 
cerns an  epidemic  in  China  in  1122  B.C.  The 
disease  was  so  prevalent  that  both  the  Chi- 
nese and  the  Hindus  established  female  di- 
vinities whose  prime  function  was  to  super- 
vise smallpox.  The  King  James  version  of 
the  Bible  calls  one  of  the  Egyptian  plagues 
in  Moses’  time  a plague  of  “boils  breaking  in- 
to blains.” 


The  first  accurate  medical  description  of 
the  disease  to  appear  in  print  was  by  the 
Bishop  of  Lausanne  in  570  A.D.  Twelve  years 
later  Bishop  Gregory  of  Tours  described  the 
disease  as  an  “epidemic  disease  beginning 
with  fever  and  backache  and  attended  with 
pustular  eruption.” 

The  man  who  did  most  to  conquer  small- 
pox was  Edward  Jenner,  an  English  physi- 
cian. In  1796  he  noticed  that  girls  who 
milked  cows  often  were  afflicted  by  blister- 
like eruptions  on  their  hands.  But  in  the 
severe  epidemic  that  killed  more  than  24,000 
Londoners  in  ten  years,  none  of  the  milk- 
maids got  the  disease. 

In  a history-making  experiment,  Jenner 
vaccinated  an  eight  year  old  boy  with  ma- 
terial taken  from  an  eruption  on  a milk- 
maid’s hands.  To  prove  his  theory  Jenner 
waited  a few  weeks  and  reinoculated  the  boy 
with  pure  smallpox  virus  isolated  from  a 
victim  of  the  disease.  The  boy  did  not  get 
sick,  and  Jenner  had  ushered  in  a new  era  of 
preventive  medicine. 

The  chicken’s  role  in  this  fight  against 
smallpox  was  firmly  established  when 
Lederle  scientists  determined  that  among 
4,500  people,  the  new  vaccine  gave  immunity 
identical  to  the  older  calf-grown  types. 

Smallpox  can  be  held  in  check  only  by  con- 
stant immunization  of  the  entire  population. 


06 


J.  M.  A.  ALABAMA 


around  the  state 


DIABETES— Dr.  Leon  S.  Smelo  (left)  was 
elected  president  of  the  reorganized  Alabama 
Diabetes  Association  at  its  first  annual  meet- 
ing at  the  Grand  Hotel  on  June  25.  Dr.  Buris 
R.  Boshell  (right)  was  named  secretary- 
treasurer.  Dr.  S.  J.  Selikoff  (not  shown) 
was  elected  vice  president. 

Guest  speakers  at  the  meeting  were  (below, 
left  to  right)  Dr.  Henry  Ricketts,  University 
of  Chicago  Medical  School;  Dr.  James  Craig, 
Western  Reserve  University;  Dr.  Samuel 
Beaser,  director  of  Diabetes  Clinic,  Beth 
Israel  Hospital,  Boston;  Dr.  Joseph  Shipp,  di- 
rector of  education  for  the  Joslin  Clinic,  New 
England  Hospital,  Boston. 


AUGUST  I960— VOL.  30,  NO.  2 


107 


INTERNISTS— Dr.  J.  O.  Finney,  Gadsden  (left),  i 
was  installed  as  president  of  the  Alabama  Society 
of  Interna]  Medicine  at  the  Grand  Hotel,  Point 
Clear  on  June  25.  Dr.  Marvin  Woodall  of  Birming-  !i 
ham  (center)  was  named  president-elect;  and  Dr.  ) 
John  Burnum,  Tuscaloosa,  was  elected  a member 
of  the  Executive  Committee.  Dr.  William  F.  Haw-  • 
ley,  Birmingham  (not  shown)  was  named  secre-  i 
tary-treasurer.  ■ 


' ( 


ALABAMA  HEART  ASSOCIATION— 
Elected  Dr.  David  Owensby,  Tallassee 
(left  to  right)  vice  president;  Dr.  Harry 
M.  Simpson,  Jr.,  Florence,  president- 
elect; Dr.  J.  Randolph  Penton,  Mont- 
gomery, president;  and  Dr.  W.  B.  From- 
meyer,  Jr.,  chairman  of  the  Board  of 
Directors,  at  its  annual  business  meet- 
ing in  Poinl  Clear  on  June  25. 


LILLY  ROAD  SHOW— The  Black  Belt  Chapter  of  the  i 
Alabama  Academy  of  General  Practice  held  Alabama’s  I 
first  Eli  Lilly  Road  Show  in  Selma  on  June  16.  Dr.  ; 
Samuel  B.  Nadler,  professor  of  clinical  medicine  of  Tu-  : 
lane  Univeisity  (left,  front  row  center)  spoke  on  the 
thyroid  gland.  Pictured  with  Dr.  Nadler  are  (left  to  ; 
right)  Drs.  Fred  Whitfield,  Jr.,  Demopolis;  William  E.  : 
Ehlert,  Selma;  L.  R.  Burroughs,  Birmingham;  Marshall  ; 
L.  Michel,  associate  professor  of  surgery  and  senior  1 
surgeon  of  Touro  Infirmary  of  New  Orleans,  who  spoke  J 
on  surgery  of  the  gall  bladder;  Winston  A.  Edwards, |t 
Wetumpka;  Julian  P.  Howell  of  Selma.  || 


: GP  SEMINAR  SPEAKERS— Speaking  at  the  21st 
, postgraduate  seminar  of  the  Alabama  Academy  of 
i General  Practice  in  Mobile  on  August  24-25  will  be 
! (clockwise  from  top)  Dr.  R.  H.  Kampmeier,  pro- 
; fessor  of  medicine  at  Vanderbilt  University  and 
Editor  of  the  Southern  Medical  Journal,  who  will 
deliver  the  annual  James  S.  McLester  Lecture; 
Colonel  Harold  V.  Ellingson,  Commander  of  the 
Medical  Service  School,  USAF,  Gunter  Air  Force 
Base,  who  will  lecture  on  “Problems  Of  Handling 
Mass  Casualties”;  Dr.  William  D.  Davis,  Jr.,  Head, 
\ Gastroenterology  Department  of  Ochsner  Clinic  in 
! New  Orleans,  who  will  speak  on  “Hepatitis”;  and 
:1  Mr.  Vann  Pruitt,  Jr.,  who  will  discuss  “The  Use 
^ of  Toxicology  By  The  General  Practitioner”. 


LEARNING  CAN  BE  FUN— This  month  in 
the  rolling  clay  hills  around  Citronelle  90 
boys  and  girls  are  enjoying  a two-week  en- 
campment despite  the  fact  that  they  are 
handicapped. 

The  children,  ranging  in  ages  from  eight  to 
fourteen,  have  as  much  fun  as  the  average 
normal  camper.  They  swim,  ride  horses, 
have  rifle  and  archery  practice,  go  canoeing 
and  sailing,  and  engage  in  handicraft  work. 

But  unlike  most  summer  camps,  campers 
enrolled  at  Camp  Seale  Harris  are  learning 
that  they  can  live  a normal  life  like  any 
youngster  in  spite  of  their  handicapping  dis- 
ease . . . diabetes. 

The  young  campers  learn  how  to  enjoy 
normal  outdoor  activities  as  well  as  how  to 
care  for  themselves  as  diabetics  under  the 
watchful  eyes  of  counselors,  medical  tech- 
nicians, and  registered  nurses  who  are  su- 
pervised by  physicians. 

Camp  Seale  Harris  was  founded  twelve 
years  ago  by  the  Diabetic  Clinic  of  Mobile, 
Inc.  It  is  named  in  honor  of  Doctor  Seale 
Harris  of  Birmingham  who  devoted  much  of 
his  life  to  working  with  metabolic  diseases. 
Doctor  Harris  was  awarded  the  American 
Medical  Association’s  highest  award  in  1949 
for  his  work  in  diseases  of  the  pancreas. 

In  its  twelve  years  of  operation  Camp  Seale 
Harris  has  enrolled  children  from  Florida. 
Mississippi,  Louisiana,  Georgia,  Texas,  Ten- 
nessee, South  Carolina,  and  Alabama. 


MEDICAL  CENTER  NEWS 

B 


NEW  CHILDREN'S  HOSPITAL 
NAMED  FOR  ROBERT  MEYER 

The  new  three  million  dollar  Children’s 
Hospital  now  under  construction  at  the  Medi- 
cal Center  will  bear  the  name  of  Robert  R. 
Meyer,  the  man  whose  original  bequest  of 
$500,000  launched  its  building  fund.  Mrs.  T. 
Felton  Wimberly,  Jr.,  chairman  of  the  hos- 
pital’s board,  announced  recently  that  the 
main  building  of  the  new  facility  would  be 
named  in  honor  of  Mr.  Meyer  who  died  in 
1950  and  whose  generosity  made  possible  the 
thought  of  a new  and  larger  hospital.  The 
cost  of  the  new  facility  is  being  covered  by 
Mr.  Meyer’s  and  other  legacies,  public  and 
private  donations,  and  a federal  grant  under 
the  Hill-Burton  program. 

The  Robert  R.  Meyer  Children’s  Hospital, 
housing  approximately  130  beds,  will  be 
ready  for  occupancy  within  a year.  The  prop- 
erty upon  which  the  new  hospital  is  being 
constructed  was  purchased  with  funds  from 
the  Meyer  Foundation,  another  philanthropic 
project  started  by  Mr.  Meyer,  whose  brother 
is  now  serving  as  a member  of  the  Founda- 
tion’s board  of  directors. 


FOUNDATION  TO  OFFER 
NURSING  SCHOLARSHIPS 

A program  to  provide  scholarships  for  stu- 
dent nurses  and  to  aid  in  the  recruiting  of 
young  persons  for  the  nursing  profession  was 
announced  recently  by  Judson  B.  Branch, 
president  of  the  Allstate  Foundation. 

Branch  said  this  new  program  of  the  All- 
state Foundation  will  begin  in  1960  and  will 
make  possible  the  awarding  of  an  estimated 
50  scholarships  or  more  annually  to  young 
persons  who  plan  to  enter  the  nursing  pro- 
fession. 


The  scholarship  program  has  been  worked 
out  in  close  cooperation  with  the  National 
League  for  Nursing,  and  the  awards  will  en- 
able students  to  attend  schools  which  are 
accredited  by  the  League. 

Branch  said  Allstate  is  convinced  the  in- 
surance industry  has  a distinct  responsibility 
in  the  field  of  nursing,  “because  there  is  a 
growing  shortage  of  nurses  to  meet  the  needs 
of  the  nation’s  rapidly  expanding  population.” 

“We  are  hopeful  that  we  can  expand  our 
scholarship  program  in  coming  years,  helping 
alleviate  the  serious  condition  which  is 
pointed  out  by  recent  studies  of  the  National 
League  for  Nursing  and  other  groups,” 
Branch  said.  “At  the  same  time  that  we  are 
granting  these  scholarships,  we  shall  be  doing 
our  best  to  interest  other  foundations  and 
corporations  in  the  nursing  scholarship  plan; 
and  we  shall  be  working  closely  with  the 
National  League  for  Nursing  and  other 
groups  in  helping  interest  young  women  and 
men  in  becoming  nurses.” 

Arrangements  for  awarding  the  scholar- 
ships will  be  made  through  local  nursing 
schools,  with  none  of  the  applicants  applying 
directly  to  the  Allstate  Foundation. 


JOSEPH  HEROD  WINNER 
OF  McLaughlin  award 

Joseph  W.  Herod  of  Orrville,  senior  medi- 
cal student,  has  been  named  recipient  of  the 
J.  D.  McLaughlin  Award  for  1960.  Estab- 
lished in  1957,  the  one  hundred  dollar  award 
is  limited  to  members  of  the  Phi  Beta  Pi 
medical-social  fraternity  and  is  given  to  en- 
courage summer  research  by  a medical  stu- 
dent in  one  of  the  many  departments  of  the 
University  of  Alabama  Medical  Center. 


AUGUST  I960— VOL.  30,  NO.  2 


MEDICAL  CENTER  NEWS 


Mr.  Herod’s  work  was  done  in  the  depart- 
ment of  medicine  under  the  direction  of  Dr. 
Samuel  Richardson  Hill,  Jr.  and  Dr.  Howard 
L.  Holley. 

Mr.  flerod’s  field  of  study  was  conducted 
in  the  endocrinology  laboratories  of  the  Uni- 
versity Hospital  and  the  Veterans  Adminis- 
tration Hospital  during  the  summers  of  1958 
and  1959  and  was  concerned  with  certain 
areas  of  metabolism  and  the  use  of  certain 
drugs  in  the  investigation  of  responsiveness 
of  the  adrenal  glands. 

Dr.  J.  D.  McLaughlin,  for  whom  the  award 
was  named,  was  a 1910  graduate  of  the  Medi- 
cal College  of  Alabama  when  it  was  located 
in  Mobile  and  practiced  medicine  in  Blue 
Springs  until  his  death  in  1953.  His  three 
sons,  also  Alabama  physicians  and  University 
of  Alabama  graduates,  inaugurated  the  award 
in  memory  of  their  father  four  years  ago. 
They  are  Dr.  Leon  D.  McLaughlin  and  Dr. 
Robert  J.  McLaughlin,  both  of  whom  prac- 
tice in  Ozark,  and  Dr.  Max  V.  McLaughlin 
whose  medical  practice  is  in  Mobile. 


LOCAL  FACULTY  MEMBERS 
RECEIVE  HEART  GRANTS 

Nine  members  of  the  Medical  Center  staff 
have  been  awarded  grants-in-aid  totaling 
$40,500  to  conduct  research  on  diseases  of  the 
heart  and  vascular  system,  according  to  an 
announcement  by  Dr.  Walter  B.  Frommeyer, 
Jr.,  professor  and  chairman  of  the  department 
of  medicine  and  chairman  of  the  board  of  the 
Alabama  Heart  Association.  In  addition  to 
these  awards  from  the  Alabama  affiliate  of 
the  American  Heart  Association,  $31,000  from 
the  national  AHA  have  been  donated  to  cardi- 
ological research  in  the  state,  bringing  the 
total  for  Heart-Fund-supported  research  in 
Alabama  for  1960-1961  to  $71,500. 

Dr.  Lionel  M.  Bargeron,  Jr.,  associate  pro- 
fessor of  pediatric  cardiology,  has  been 
awarded  $5,000  to  study  the  clinical  develop- 
ment of  the  hydrogen  electrode  for  evalua- 
tion of  cardiac  shunts.  Dr.  Samuel  B.  Baker, 

I 12 


professor  of  pharmacology,  received  $4,500  to 
study  blood  vessel  responses  to  thyroxin.  Dr. 
Joseph  K.  Brantley,  Jr.,  research  fellow  in 
the  department  of  medicine,  will  have  $5,000 
to  conduct  studies  in  man  on  secondary  hy- 
peraldosteromism.  Dr.  W.  Sterling  Edwards, 
associate  professor  of  surgery,  was  granted 
$8,000  for  further  development  of  vascular 
prostheses:  arterial  grafts,  aortic  valve  re- 

placement, and  intra-cardiac  patches.  Dr. 
Leland  C.  Clark,  associate  professor  of  bio- 
chemistry in  the  department  of  surgery,  was 
given  $7,000  for  electrochemical  methods  for 
studying  circulation.  Dr.  I.  Ernest  Gonzales, 
research  fellow  in  the  department  of  path- 
ology, received  the  sum  of  $9,680  for  chemical 
and  microscopic  studies  of  human  arteries  to 
determine  primary  indications  of  arterio- 
sclerosis. 


MOUND  STATE  PARK 
SITE  OF  RESEARCH 

Grants  totaling  $43,092  awarded  by  the  Na- 
tional Institutes  of  Health  have  made  possi- 
ble a research  program  headed  by  Dr.  E.  Carl 
Sensenig,  professor  and  chairman  of  the  de- 
partment of  anatomy  and  honorary  curator 
of  the  physical  anthropology  for  the  Alabama 
Museum  of  Natural  History.  Beginning  this 
summer.  Dr.  Sensenig,  several  dental  and 
graduate  students,  and  archaeologist  David 
De  Jarnette  will  study  the  physical  char- 
acteristics of  Alabama’s  prehistoric  citizens. 
The  researchers  will  study  skeletal  excava- 
tions of  the  past  30  years  found  at  Mound 
State  and  other  Alabama  localities  in  order  to 
make  comparisons  between  ancient  and  mod- 
ern physical  characteristics  and  to  gain 
knowledge  of  the  reasons  for  the  contrasts. 
Anthropological  study  of  this  nature  is  valu- 
able not  only  for  the  important  facts  it  un- 
covers but  for  aiding  future  dentists  in  their 
training  by  requiring  them  to  make  anthro- 
pometric measurements  of  the  skeletal  ma- 
terial. 


J.  M.  A.  ALABAMA 


STATE  OEPARTMENT  OF  HEALTH 


BUREAU  OF  ADMINISTRATION 

D.  G.  Gill,  M.  D. 

State  Health  Officer 


CONTROL  OF  RADIATION 

(Based  on  a paper  by  Dr.  Sidney  L.  Miller, 
D.  D.  S.,  Bureau  of  Dental  Hygiene,  State 
Health  Department.) 

The  Alabama  Legislative  Council  has 
agreed  to  study  the  possibility  of  recom- 
mending legislation  which  would  provide  for 
establishment  of  a State  Health  Department 
agency  to  inspect  X-ray  equipment  of  hos- 
pitals, dentists,  physicians,  chiropractors,  and 
other  users  of  X-rays  and  radioactive  ma- 
terial. This  proposal  was  submitted  to  the 
Council  by  the  Health  Department. 

Traditionally,  the  Health  Department  has 
been  responsible  for  seeing  that  every  activ- 
ity within  its  jurisdiction  is  carried  on  in  such 
a way  that  the  health  of  the  public  is  not  en- 
dangered. Fulfillment  of  this  responsibility 
often  involves  the  control  or  removal  of  vari- 
ous hazards.  Such  a hazard,  one  that  has 
come  to  the  forefront  in  recent  years,  is  that 
of  indiscriminate  and  unnecessary  exposure 
to  ionizing  radiations. 

Exposure  to  ionizing  radiations  is  not  a 
new  phenomenon.  Since  the  beginning  of 
time  man  has  been  subject  to  background 
radiation  from  such  natural  sources  as  cosmic 
rays  and  various  materials,  commonly  known 
as  radionuclides,  which  lie  embedded  in  the 
earth’s  crust. 

We  could,  however,  afford  to  be  complacent 
about  radiation  until  the  first  atomic  bomb 
was  released  on  Hiroshima.  The  effects  of 
this  explosive  unleashed  energy  are  still  be- 
ing observed  and  evaluated.  The  potential 
hazards  of  ionizing  radiations  were  suddenly 
emphasized  to  an  unsuspecting  world  which 
before  the  atom  was  split  gave  little  thought 
to  radiation  as  a potential  threat  to  life  and 
health. 

AUGUST  I960— VOL.  30,  NO.  2 


The  period  since  the  end  of  World  War  11 
has  seen  increased  research  designed  to  find 
uses  for  nuclear  energy  for  peaceful  as  well 
as  military  purposes.  Accelerated  develop- 
ment and  construction  of  nuclear  reactors  has 
characterized  the  past  few  years.  The  world’s 
need  for  new  sources  of  energy  and  the  ur- 
gency of  the  race  to  develop  new  and  more 
powerful  weapons  seem  to  have  outweighed 
consideration  of  the  possible  harm  which  may 
accompany  the  utilization  of  nuclear  energy. 
It  is  true  that  some  of  the  by-products  of  the 
release  of  nuclear  energy  show  promise  of 
revolutionizing  medicine,  agriculture,  indus- 
try, and  research.  These  by-products,  radio- 
isotopes, although  useful  are,  nevertheless, 
sources  of  radiation.  Furthermore,  not  all  the 
by-products  of  nuclear  fission  are  useful. 
There  are  many  waste  products.  These  waste 
products  also  produce  ionizing  radiations. 
Thus,  the  potential  sources  of  ionizing  radia- 
tions are  increasing  rapidly. 

The  actual  degree  of  danger  from  current 
sources  of  radiation  is  uncertain.  There  are 
sources  about  which  we  probably  have  no  in- 
formation and  over  which  we  can  exercise 
no  control — radioactive  fall-out  from  weap- 
ons testing,  for  example.  It  is  certain,  how- 
ever, that  radiation  hazards  are  real  and  that 
exposures  as  well  as  effects  are  cumulative. 
Furthermore,  the  effects  of  radiations  are 
irreversible  and  may  not  develop  for  many 
years  after  exposure.  Therefore,  if  we  wait 
for  obvious  signs  of  radiation  damage  to  ap- 
pear in  the  population — or  in  the  individual — 
it  will  be  too  late  to  help  to  relieve  the  prob- 
lem of  over  exposure.  In  this  situation  pre- 
vention is  imperative,  not  merely  desirable. 
It  is  apparent  that  all  unnecessary  radiation 
exposure  should  be  avoided.  In  other  words, 

I 13 


A 


DEPARTMENT  OF  HEALTH 


we  should  exercise  some  measure  of  control 
over  known  sources  of  radiation.  At  the 
same  time,  there  should  be  no  interference 
with  practical  utilization  of  the  sources  of 
radiation. 

A major  source  of  radiation  today  is  the 
X-ray  machine.  The  use  of  the  X-ray  ma- 
chine for  diagnosis  and  treatment  in  medicine 
and  in  dentistry  is  responsible  tor  repeated 
exposures  of  limited  portions  of  the  body  to 
small  amounts  of  radiation.  While  there  is 
no  doubt  that  the  use  of  the  X-ray  is  essential 
in  the  practice  of  the  healing  arts,  it  must  be 
conceded  that  we  do  not  yet  know  at  what 
point  harmful  effects  of  prolonged  low-level 
exposure  may  outweigh  its  benefits.  It 
should  be  mentioned,  too,  that  the  fluroscope 
is  another  source  of  radiation  which  is  po- 
tentially dangerous. 

So  far,  the  value  of  the  X-ray  in  medicine 
and  dentistry  far  outweighs  any  of  its  possi- 
ble deleterious  effects.  A program  in  con- 
trol or  prevention  of  excess  exposure  to  radia- 
tion must  therefore  aim  against  careless  and 
indiscriminate  use  of  the  X-ray,  against  un- 
necessary or  poorly  performed  X-ray  exami- 
nations, against  failure  to  provide  shielding 
equipment  for  patient  as  well  as  personnel, 
against  failure  to  monitor  equipment,  againsL 
failure  to  replace  hazardous  equipment, 
against  routine  fluoroscopy  of  infants  and 
children  who  are  particularly  vulnerable  to 
radiation,  against  routine  X-ray  examinations 
of  any  sort,  and  against  use  of  the  X-ray  by 
persons  without  sufficient  training  and  ex- 
perience. 

The  objective  of  such  a program  of  control, 
would  not  be  to  restrict  the  number  of  X-ray 
exposures  made  but  rather  to  make  each  with 
a minimum  of  exposure  and  to  make  each 
one  count.  Radiation  exposure  would  be  re- 
stricted to  the  tissue  under  examination,  and 
there  would  be  a definite  purpose  for  each 
exposure.  Such  a control  program  begins,  of 
course,  with  the  individual  physician  or  den- 
tist since  he  is  the  person  who  must  de- 
termine when  and  how  often  exposure  of  the 
individual  patient  is  warranted.  The  pro- 
posed Health  Department  program  would 

I 14 


augment  the  efforts  of  the  individual  prac- 
titioner by  assuming  responsibility  for  the 
safety  of  the  X-ray  equipment  used  at  his 
direction. 

The  Health  Department,  through  the  Bu- 
reau of  Dental  Hygiene,  has  already  initiated 
limited  activity  in  this  field.  All  dentists 
licensed  to  practice  in  the  state  have  been 
offered  filtration  and  collimation  material 
for  their  X-ray  machines.  This  material  is 
in  accordance  with  recommendations  of  the 
National  Bureau  of  Standards.  To  date,  ma- 
terial has  been  supplied  for  over  600  ma- 
chines. 

Also,  the  Bureau  of  Dental  Hygiene  early 
this  year  sponsored  a brief  course  in  radi- 
ological health  for  Alabama  dentists  and 
their  auxiliary  personnel.  A total  of  327  per- 
sons attended  the  course,  the  purpose  of 
which  was  to  give  the  dentist  more  under- 
standing of  the  principles  and  hazards  of 
ionizing  radiations. 

The  Health  Department  film  library  has  a 
motion  picture,  “Radiation:  Physician  and 

Patient.”  This  16  mm,  45  minute,  color  film 
was  produced  by  the  American  College  of 
Radiology  in  cooperation  with  the  U.  S.  Pub- 
lic Health  Service.  The  film  is  essentially 
an  informal  talk  about  medical  radiology,  the 
problems  it  raises,  its  biological  effects,  its 
physical  behavior,  and  its  proper  use  in  clini- 
cal examinations.  The  film  is  for  showing 
only  to  physicians,  dentists,  and  X-ray  tech- 
nicians. It  may  be  borrowed  from  the  film 
library  at  no  charge  except  for  return  post- 
age. 


HIGHWAY  ACCIDENTS 

There  were  900  more  deaths  and  more  than 

50.000  additional  injuries  on  U.  S.  highways 
in  1959  than  was  the  case  in  1958,  according 
to  statistics  compiled  by  the  Travelers  Insur- 
ance Companies. 

Fatalities  climbed  to  37,600  and  more  than 

2.870.000  were  injured  as  a result  of  automo- 
bile accidents. 

The  report  shows  that  drivers  under  25 
years  of  age  were  involved  in  nearly  29  per 
cent  of  the  fatal  accidents. 


J.  M.  A.  ALABAMA 


DEPARTMENT  OF  HEALTH 


BUREAU  OF  PREVENTABLE  DISEASES  BUREAU  OF  VITAL  STATISTICS 


W.  H.  Y.  Smith,  M.  D.,  Director 


Ralph  W.  Roberts,  M.  S.,  Director 


CURRENT  MORBIDITY  STATISTICS 
1960 


PROVISIONAL  BIRTH  AND  DEATH  STATIS- 
TICS, APRIL  1960,  AND  COMPARATIVE  DATA 


•E.  E. 

May 

June 

June 

Typhoid  and  Paratyphoid 

3 

2 

6 

Undulant  fever.  

2 

2 

2 

Meningitis  

3 

5 

11 

Scarlet  fever...  . .....  ...  . . 

49 

37 

29 

Whooping  cough .... 

6 

5 

64 

Diphtheria  

1 

1 

4 

Tetanus  . 

1 

1 

3 

Tuberculosis  

134 

104 

210 

Tularemia  ..  

0 

0 

0 

Amebic  dysentery 

3 

9 

1 

Malaria  

0 

0 

0 

Influenza  .... 

82 

28 

87 

Smallpox  - ..  . 

0 

0 

0 

Measles  

256 

362 

721 

Poliomyelitis  

0 

0 

24 

Encephalitis  

4 

5 

1 

Chickenpox  

69 

150 

72 

Typhus  fever.. 

0 

2 

1 

Mumps  

80 

53 

132 

Cancer  

585 

406 

491 

Pellagra  

0 

0 

0 

Pneumonia  

237 

164 

159 

Syphilis  

163 

157 

167 

Chancroid  — 

1 

4 

5 

Gonorrhea  

321 

296 

364 

Rabies — Human  cases 

0 

0 

0 

Pos.  animal  heads 

9 

5 

0 

As  reported  by  physicians  and 

including  deaths  not  re- 

ported  as  cases. 

*E.  E. — The  estimated  expectancy  represents  the  median 
incidence  of  the  past  nine  years. 

,C  iZ 

BUREAU  OF  LABORATORIES 

Thomas  S.  Hosty,  Ph.D.,  Director 


SPECIMENS  EXAMINED 
June  1960 

Examinations  for  malaria  . 50 

Examinations  for  diphtheria  bacilli  and 

Vincent’s  - 64 

Agglutination  tests  _ 556 

Typhoid  cultures  (blood,  feces,  and  urine)  640 

Brucella  cultures..  1 

Examinations  for  intestinal  parasites  2,980 

Darkfield  examinations  . 1 

Serologic  tests  for  syphilis  (blood  and 

spinal  fluid) 22,686 

Examinations  for  gonococci  1,534 

Complement  fixation  tests 75 

Examinations  for  tubercle  bacilli 3,693 

Examinations  for  Negri  bodies  (smears 

and  animal  inoculations) 205 

Water  examinations 2,494 

Milk  and  dairy  products  examinations 4,448 

Miscellaneous  examinations  . 2,530 


Total 41,957 


Live  Births 
Deaths 

Causes  of  Death 

Number 

Registered 

During 

Rates* 

(Annual  Basis) 

1 Total 

*1 

White  i 

< 

Non- 

White 

1960 

1959 

1958 

Live  Births  

5,848 

3,714 

2,134 

21.9 

22.6 

22.3 

Deaths  

2,355 

1,459 

896 

8.8 

8.8 

9.2 

Fetal  Deaths..  .... 

131 

48 

83 

21.9 

20.8 

20.7 

Infant  Deaths 

under  one  month 

118 

73 

45 

20.2 

19.8 

23.9 

under  one  year 

180 

96 

84 

30.8 

30.7 

34.3 

Maternal  deaths 

4 

2 

2 

6.7 

4.9 

15.0 

Cause  of  Death 

Tuberculosis,  001-019 

23 

9 

14 

8.6 

6.4 

11.4 

Syphilis,  020-029 

3 

1 

2 

1.1 

3.0 

5.3 

Dysentery,  045-048 

1 

1 

0.4 

0.4 

0.4 

Diphtheria,  055  

! 

Whooping  cough,  056 

1 

1 

0.4 

0.4 

Meningococcal  infec- 

tions,  057 

1 

1 

0.4 

0.4 

0.4 

Poliomyelitis,  080,  081 

0.4 

0.4 

Measles,  085 

0.8 

2.3 

Malignant  neo- 

plasms,  140-205 

312 

224 

88 

116.8 

121.1 

110.5 

Diabetes  Mellitus,  260 

29 

15 

14 

10.9 

16.6 

17.2 

Pellagra,  281 

. .. 

0.4 

V'ascular  lesions  orf 

central  nervous 

systems,  330-334 

289 

170 

119 

108.2 

113.9 

118.5 

Rheumatic  fever. 

400-402  

•1 

2 

2 

1.5 

1.1 

Diseases  of  the 

heart,  410-443 

785 

507 

278 

293.9 

301.1 

320.5 

Hypertension  with 

heart  disease. 

440-443 

139 

58 

81 

52.0 

57.3 

65.2 

Diseases  of  the 

arteries,  450-456 

51 

33 

18 

19.1 

18.5 

22.1 

Influenza,  480-483 

41 

17 

24 

15.4 

3.4 

10.3 

Pneumonia,  all 

forms,  490-493 

96 

51 

45 

35.9 

21.5 

33.2 

Bronchitis,  500-502. 

9 

8 

1 

3.4 

2.3 

2.3 

Appendicitis.  550-553 

3 

1 

2 

1.1 

0.4 

0.8 

Intestinal  obstruction 

and  hernia,  560, 

561,  570  

9 

6 

3 

3.4 

6.0 

3.8 

Gastro-enteritis  and 

colitis,  under  2, 

571.0,  764  ..  _.  _ 

7 

2 

5 

2.6 

2.3 

1.1 

Cirrhosis  of  liver,  581 

15 

11 

4 

5.6 

7.9 

4.2 

Diseases  of  pregnancy 

and  childbirth. 

640.  689 

4 

2 

2 

6.7 

4.9 

15.0 

Congenital  malforma- 

tions,  750-759  

24 

16 

8 

4.1 

3.7 

4.8 

Immaturity  at  birth. 

774-776  

36 

22 

14 

6.2 

7.0 

7.0 

Accidents,  total,  800-962 

134 

76 

58, 

50.2 

56.6 

60.2 

Mortor  vehicle  acci- 

dents,  810-835  , 960._| 

50 

31 

19 

18.7 

26.4 

25.2 

All  other  defined 

1 

causes  

378 

249 

129 

141.5 

130.5 

129.6 

Ill-defined  and  un-  | 

1 

1 

known  causes,  780-  j 

i 

1 

793,  795... 1 

100' 

36 

64 

37.4  i 

38.5 

40.0 

•Rates:  Birth  and  death — per  1,000  population 
Infant  deaths — per  1,000  live  births 
Fetal  deaths — per  1,000  deliveries 
Maternal  deaths — per  10,000  deliveries 
Deaths  from  specified  causes — per  100,000  population 


AUGUST  I960— VOL.  30,  NO.  2 


DEPARTMENT  OF  HEALTH 


HOME-CARE  PROGRAMS 


Home-care  programs  successfully  serving 
the  poor  will  become  increasingly  available 
to  sick  people  of  all  income  brackets.  This  is 
the  prediction  of  Dr.  Franz  Goldmann,  asso- 
ciate professor  emeritus  of  medical  care  at 
the  Harvard  School  of  Public  Health. 

Speaking  before  the  National  Health 
Forum  on  health  needs  of  older  people,  Dr. 
Goldmann  said  that  the  trend  toward  ex- 
tension of  Blue  Cross  benefits  and  growth  of 
group-practice  prepayment  plans  will  result 
in  increasing  availability  of  both  short-term 
and  long-term  home  care. 

He  distinguished  between  house  calls  by 
physicians  and  nurses  and  comprehensive 
home-care  programs  which  “cover  all  the 
services  needed  by  home-bound  patients,  en- 
courage teamwork  of  the  various  types  of 
professional  and  auxiliary  personnel,  and 
foster  high  quality  of  service.” 

“Properly  organized  and  supervised  home- 
care  is  advantageous  to  the  sick  because  it 
permits  service  in  the  usual  environment,  as- 
sures continuity  of  care  upon  discharge  from 
the  hospital,  and  reduces  the  total  medical 
bills,”  Dr.  Goldmann  said. 

He  pointed  out  that  organized  home-care 
programs  contribute  to  the  best  possible 
utilization  of  hospital  beds  and  reduce  capi- 
tal expenditures  for  hospital  facilities.  But, 
he  added,  home-care  programs  do  not  de- 
crease operating  costs  of  hospitals,  since  a 
decrease  in  the  average  length  of  stay  of  pa- 
tients causes  an  increase  in  the  average  daily 
hospital  cost. 


OUR  ADVERTISERS 


Advertisers  in  our  journal  are  carefully 
selected.  Only  those  meeting  our  adver- 
tising standards  may  use  the  facilities  of 
our  pages.  No  advertisement  will  be  ac- 
cepted which,  either  by  intent  or  infer- 
ence, would  result  in  misleading  the 
reader.  May  we  suggest  that  you  review 
the  ads  in  each  issue  of  our  journal  and, 
when  occasion  arises  to  prescribe  products 
featured  or  use  the  facilities  offered,  tell 
them  you  saw  their  ad  in  our  journal. 


in  Us  completeness 


Digitalis  if 

0.1  Gram 

dWHBJ.lV4gr.in*)  ii 

C.^UTION;  F«)er«l  -W 

liw  prohibits  dispens-  ip 

uiic  witbotit  rb 

tion  5|; 

miS.  ftO$£  t C8..  Ui-  e'l 

8«ttBa  ii  t A & 


Each  pill  is 
equivalent  to 
one  USP  Digitalis  Unit 

Physiologically  Standardized 
therefore  always 
dependable. 

Clinical  samples  sent  to 
physicians  upon  request. 


Davies,  Rose  &.  Co.,  Ltd. 
Boston,  18,  Mass. 


I 16 


J.  M.  A.  ALABAMA 


THE  JOURNAL 

of 

THE  MEDICAL  ASSOCIATION  OF  THE  STATE  OF  ALABAMA 

Published  Under  the  Auspices  of  the  Board  of  Censors 
Vol.  30  September  1960  No.  3 


Homotransplantation  Of 
Thyroid  And  Parathyroid  Glands 
By  Vascular  Anastomosis 

WILLIAM  F.  NICKEL.  JR..  M.  D. 
J.  HERBERT  CONWAY.  M.  D. 
JAMES  W.  SMITH.  M.  D. 


New  York.  New  York 


The  fundamental  problem  underlying  the 
homotransplantation  of  whole  organs  is  one 
of  the  most  challenging  confronting  surgeons 
today.  The  term  host-rejection  as  applied  to 
the  problem  of  homctransplantation  appears 
to  involve  an  immune  reaction  whereby  an 
antigen-antibody  mechanism  is  created — the 
antigen  being  elaborated  by  the  graft  and  the 
antibody  being  represented  by  the  host’s  re- 
action to  the  homotransplant  or  antigen.  Thus 
the  fundamental  problem  would  properly 
seem  to  lie  within  the  sphere  of  the  immu- 


From  the  Department  of  Surgery  (Plastic), 
New  York  Hospital,  Cornell  Medical  College. 

Read  before  the  Alabama  Chapter  of  the  Ameri- 
can College  of  Surgeons,  Point  Clear,  February 
19,  1960. 


nologist.  None  the  less,  this  does  not  prevent 
the  surgeon  from  working  with  the  problem 
as  it  relates  to  his  own  discipline  and,  indeed, 
some  important  advances  have  been  made 
which,  though  falling  short  of  solving  the 
problem,  nevertheless  serve  to  clarify  it  to 
some  degree. 

Historical  Data  Relating  to  the 
Parathyroid  Glands 

It  was  not  until  1880  that  Sandstrom  identi- 
fied the  parathyroid  glands  as  anatomical  en- 
tities. Vassale  and  Generali  demonstrated 
that  their  removal  resulted  in  tetany  in  1895, 
and  MacCallum  and  Voegtlin  proved  that  the 
parathyroids  regulate  calcium  metabolism  in 
1909  (figure  1).  Successful  autotransplanta- 


HOMOTRANSPLANTATION  BY  VASCULAR  ANASTOMOSIS 


HISTORICAL  DATA  RELATING  TO  THE  PARATHYROID  GLANDS 


Name  Date 

Sandstrom  , _ 1880 

Vassale  and  Generali 1895 

MacCallum  and  Voegtlin ..1909 


Accomplishments 

Identified  parathyroid  glands  as  distinct  from  thy 
roid. 

Demonstrated  that  removal  of  parathyroids  re- 
sulted in  tetany. 

Demonstrated  that  the  parathyroids  regulate  cal- 
cium metabolism. 


Figure  1 


tion  of  parathyroid  tissue  has  been  carried 
out  for  over  50  years  both  in  animals  and  in 
man  beginning  with  the  experiments  of  Hal- 
sted  and  Payr  in  1906.  Homotransplantation 
of  parathyroid  tissue  has  been  reported  with 
less  encouraging  results.  Occasional  reports 
of  successful  homotransplantation  of  parathy- 
roid tissue  have  been  published  which  more 
often  than  not  failed  to  include  adequate  fol- 
lowup studies.  Some  workers  in  this  field 
have  ignored  the  problem  of  host-rejection 
while  others  have  attempted  to  minimize  or 
eliminate  this  immune  response  which  is  ac- 
tivated by  homotransplantation  of  tissue  from 
one  animal  to  another  of  the  same  species. 
Though  this  homograft  rejection  phenomenon 
seems  to  be  the  major  obstacle  in  the  success- 
ful homografting  of  organs,  the  techniques  of 
transplantation  may  also  play  a significant 
role  in  the  subsequent  fate  of  the  graft.  Ma- 
jor efforts  of  workers  in  this  field  have  re- 
volved around  two  basic  considerations,  1) 
the  preparation  of  the  transplant,  and  2)  the 
technique  of  transplantation.  The  values  of 
fetal  versus  adult  tissues  and  of  normal  ver- 
sus abnormal  parathyroid  tissues  have  been 
investigated.  The  merits  of  adaptation  of  tis- 
sues have  been  explored.  Free  grafts  have 
been  implanted  immediately,  others  have 
been  adapted  to  the  serums  and  tissue  cul- 
tures and  transplanted  after  an  interval.  Fi- 

I 18 


nally,  whole  thyroid  glands  with  attached 
parathyroids  have  been  transplanted  by  vas- 
cular anastomosis. 

Experimental  Transplantation  of  Free 
Grafts  of  Parathyroid  Glands  in 
Animals 

In  1906,  Halsted  began  a series  of  experi- 
ments involving  auto-  and  homotransplanta- 
tion of  free  transplants  of  parathyroid  tissue 
in  animals  and  demonstrated  that  successful 
autotransplantation  of  parathyroid  tissue  in 
dogs  was  dependent  upon  a physiological  de- 
ficiency (figure  2).  When  such  a deficiency 
was  created  61%  of  his  experimental  animals 
accepted  the  autotransplant  successfully.  This 
led  to  the  assumption  of  Halsted’s  “law  of  de- 
ficiency,” which  is  disputed  by  some  investi- 
gators today.  All  of  Halsted’s  attempts  at 
homotransplantation  of  tissue  in  animals 
were  unsuccessful.  At  approximately  the 
same  time,  Payr  began  a series  of  experi- 
ments working  with  animals,  and  also  suc- 
ceeded in  autotransplanting  thyroid  tissue 
successfully.  In  1934,  Stone,  Owings  and  Gey 
suggested  a new  approach  to  the  problem. 
Bits  of  parathyroid  tissue  were  grown  in  tis- 
sue culture  and  adapted  to  the  host  by  the 
addition  of  the  recipient’s  serum  to  the  tis- 


•J.  M.  A.  ALABAMA 


HOMOTRANSPLANTATION  BY  VASCULAR  ANASTOMOSIS 


EXPERIMENTAL  TRANSPLANTATION  OF  FREE  GRAFTS 
OF  PARATHYROID  GLANDS  IN  ANIMALS 


Name  Date 

Halsted  ^ — 1906-1909 

Payr  - 1906 

Stone,  Owings,  Gey — 1934 

Pinkus,  Maddock,  Coller  1937 

Reid,  Ransohoff  1943 

Algire  - 1954 

Braunwald,  Hufnagel  — 1958 

Jordan,  Foster,  Gyorkey — — 1958 

Swan  et  al — - 1959 


Experiment 

Successful  autotransplantation  in  animals.  Unsuccessful 
homotransplantation  (animals). 

Successful  autotransplantation  (animals). 

Adaptation  of  parathyroid  tissue  in  host’s  serum  in  tissue 
culture  (animals). 

Adaptation  by  Sterne’s  Method.  Adverse  effect  on  homo- 
transplants. No  effect  on  autotransplants,  (animals) 

Pulmonary  emboli  of  parathyroid  tissue  via  jugular  vein 
(animals). 

Diffusion  chamber  technique  (mice). 

Dispute  Halsted’s  law  of  deficiency,  importance  of  graft 
site,  adaptation  in  tissue  culture  & age  of  donor. 

Diffusion  chamber — 0. 

Axillary  vein — 25%  success  autografts. 

Sterno — thyroid  m. — 30%  success  autografts  (dogs). 

No  function  in  diffusion  chambers,  (dogs) 


Figure  2 


sue  culture.  By  implanting  thin  sheets  of 
cells  rather  than  gross  pieces  of  tissue  it  was 
hope(i  that  successful  homotransplantation 
could  be  accomplished.  They  reported  suc- 
cessful homotransplantation  of  parathyroid 
tissue  in  dogs  in  this  manner.  The  following 
factors  were  thought  to  be  important;  1)  the 
site  of  transplantation  should  be  in  a relative- 
ly avascular  area  but  adjacent  to  a vascular 
area  such  as  the  axilla,  2)  thin  sheets  and  tiny 
particles  of  tissue  offered  a better  chance  of 
survival  than  large  pieces  of  tissue,  3)  incom- 
patibility or  host-rejection  could  be  decreased 
by  adaptation  of  the  donor’s  tissue  to  the  re- 
cipient’s serum  in  tissue  culture,  and  4)  the 
age  of  the  tissue  for  transplantation — the 
younger  the  donor,  the  greater  the  chance  for 
survival. 

In  1937,  Pinkus,  Maddock  and  Coller  com- 
pared transplants  adapted  in  tissue  culture  by 
the  method  of  Stone  with  those  not  adapted 
and  came  to  the  conclusion  that  homotrans- 
plants adapted  in  tissue  culture  gave  poorer 
results  than  those  of  any  other  group,  and 
that,  indeed,  adaptation  in  the  host’s  serum 
appeared  to  have  an  adverse  effect  on  the  suc- 
cess of  homotransplants.  Tissue  culture  did 
not  appear  to  affect  autotransplants  in  ani- 
mals. 

Another  approach  to  the  problem  was  sug- 

SEPTEMBER  I960— VOL.  30,  NO.  3 


gested  by  Reid  and  Ransohoff  in  1943.  These 
investigators  produced  pulmonary  emboli 
consisting  of  parathyroid  tissue  introduced 
into  the  pulmonary  circulation  via  the  jugu- 
lar vein.  They  demonstrated  at  necropsy 
that  pulmonary  implants  had  persisted  in  sev- 
eral dogs.  This  method  has  not  been  applied 
to  humans  insofar  as  I am  aware. 

In  1954,  Algire  and  associates  published 
their  work  on  homotransplantation  of  tumor 
tissue  utilizing  a diffusion  chamber  consist- 
ing of  two  plexiglas  rings  covered  with  a 
plastic  material  which  allowed  fluids  to  dif- 
fuse into  and  out  of  the  chamber  but  pre- 
vented the  ingress  of  reticulo-endothelial 
cells  into  the  chamber.  Theoretically,  this 
would  allow  nutrient  fluids  to  nourish  the 
graft  and  would  allow  hormones  elaborated 
by  the  graft  to  pass  into  the  circulation  of  the 
host.  At  the  same  time  it  would  crevent  the 
formation  of  antibodies  by  the  host  since  the 
reticulo-endothelial  cells  of  the  host  were 
unable  to  make  contact  with  the  homograft 
and  presumably  are  the  source  of  antibody 
formation.  Algire  described  a series  of  ex- 
periments showing  that  homologous  implants 
contained  in  these  chambers  will  survive  al- 
most indefinitely  in  mice  if  protected  from 
direct  contact  with  the  host’s  tissues  by  the 
filter.  On  the  other  hand  recent  experiments 

I 19 


HOMOTRANSPLANTATION  BY  VASCULAR  ANASTOMOSIS 


in  animals  by  Braunwald  and  Hufnagel  seem 
to  minimize  the  importance  of  many  of  these 
factors,  especially  the  graft  site,  the  presence 
or  absence  of  a deficiency,  the  importance  of 
modifying  the  graft  by  growth  in  tissue  cul- 
ture and  the  age  of  the  donor  or  any  of  these 
factors  in  combination. 

In  1958,  Jordan,  Foster  and  Gyorkey  re- 
ported that  their  experiments  on  dogs  regard- 
ing autotransplantation  of  parathyroid  tis- 
sues were  unsuccessful  when  placed  in  the 
millipore  diffusion  chamber.  When,  how- 
ever, free  autografts  were  placed  into  the 
sheath  of  the  axillary  vein  25%  were  success- 
ful. When  the  autografts  were  placed  into 
the  sterno  thyroid  muscle  30%  were  success- 
ful, but  when  the  whole  thyroid-parathyroid 
complex  was  transplanted  by  vascular  anas- 
tomosis 88%  were  successful.  Likewise, 
Swan  and  his  group  could  find  no  function  in 
parathyroid  tissues  transplanted  in  diffusion 
chambers  in  dogs. 

Homotrans plantation  of  Free  Grafts  of 
Parathyroid  Tissue  in  Humans 

All  of  Halsted’s  attempts  at  free  grafts  of 
parathyroid  tissue  in  humans  were  unsuccess- 
ful. On  the  other  hand.  Stone,  Owings  and 
Gey,  using  the  tissue  culture  technique  of 
adapting  the  graft  to  the  patient’s  serum,  re- 


ported in  1934  that  two  out  of  ten  grafts  using 
this  technique  were  successful  (figure  3). 
In  1937,  Pinkus,  Maddock  and  Coder  collect- 
ed from  the  literature  59  cases  in  which  homo- 
transplantation of  free  grafts  of  parathyroid 
tissue  had  been  performed  in  humans.  They 
came  to  the  conclusion  that  in  only  9 out  of 
these  59  grafts  could  improvement  be  attrib- 
uted to  the  graft  and  that  relapses  were  noted 
in  most  of  these  if  observations  were  contin- 
ued for  several  years.  Single  cases  have  been 
reported  by  Houghton  in  1939,  by  Peycelon  in 
1947,  and  by  Bland  in  1949,  using  tissue  adapt- 
ed in  tissue  culture.  Gaillard  reported  34 
patients  in  whom  he  had  performed  homo- 
transplantations of  free  grafts  of  parathyroids 
in  humans.  Gaillard  used  a technique  similar 
to  Stone’s  but  modified  to  the  extent  that 
graded  increments  of  the  host’s  serum  were 
added  to  the  tissue  culture  containing  the 
graft  for  a period  of  14  days.  He  reported  7 
successful  grafts  out  of  34  transplants.  Esca- 
milla pursuing  Gaillard’s  study  also  reported 
7 successful  grafts.  In  addition  to  using  fetal 
transplants  he  also  used  adenomatous  para- 
thyroid tissue  for  his  transplants.  In  1959, 
Snyderman  reported  the  successful  utiliza- 
tion of  fetal  parathyroids  taken  from  a 12-14 
week  fetus  and  implanted  directly  into  the 
subcutaneous  tissue  of  a patient  suffering 
from  hypoparathyroidism.  Snyderman  theo- 


HOMOTRANSPLANTATION  OF  FREE  GRAB'TS  OF  PARATHYROID  TISSUE  IN  HUMANS 


Name 

Date 

Unsuccessful 

Success 

Halsted 

1906-1908 

All 

0 

Stone,  Owings,  Gey 

1934 

8 

2 

Pinkus,  Maddock,  Coller 

1937 

50 

9 

Houghton 

1939 

1 

Peycelon 

1947 

1 

Bland 

1949 

1 

Gaillard 

1955 

27 

7 (Stone) 

Escamilla 

1957 

4 

7 (adenoma) 

Snyderman 

1959 

1 (fetal) 

Brooks 

1960 

1 ( chamber ) 

Total 

89 

30 

Figure  3 


120 


J.  M.  A.  ALABAMA 


HOMOTRANSPLANTATION  BY  VASCULAR  ANASTOMOSIS 


rized  that  by  utilizing  fetal  tissue  early  in 
gestation  he  could  circumvent  the  immune 
reaction  before  an  antigen  had  time  to  de- 
velop in  the  fetal  tissues.  He  stated  that  one 
patient  has  been  improved  by  this  technique 
and  has  required  no  replacement  therapy  for 
a period  of  eleven  months.  However,  he  has 
since  stated  that  this  patient  again  exhibits 
marked  signs  of  hypoparathyroidism  and  so 
far  as  he  is  concerned  is  a failure.  In  1960, 
Brooks  reported  that  a homotransplant  of 
parathyroid  tissue  implanted  by  using  the  dif- 
fusion chamber  of  Algire  was  successful  in  a 
50  year  old  woman  with  hj^poparathyroidism 
of  11  years  duration.  These  transplants  seem- 
ed to  function  over  a six-month  period  fol- 
lowing implantation  of  as  many  as  a dozen 
millipore  chambers  containing  parathyroid 
tissue.  However,  recently  Brooks  stated  that 
this  patient  again  requires  replacement 
therapy. 

Vascular  Anastomosis 

The  establishment  of  an  adequate  blood 
supply  to  the  graft  would  seem  to  be  a pre- 
requisite to  successful  function.  With  this 
in  mind  Carrel  and  Guthrie-^  (figure  4)  per- 
formed autotransplantation  of  the  entire  thy- 
roid gland  and,  incidentally,  the  parathyroids 
in  dogs  in  1905,  employing  direct  vascular 
anastomosis  to  insure  an  adequate  blood  sup- 


ply. These  workers  extirpated  the  thyroid 
gland  of  a dog  with  its  intact  blood  supply, 
placed  it  in  isotonic  saline  for  a few  minutes 
and  then  replaced  it  in  the  neck,  anastomos- 
ing the  blood  vessels  but  reversing  the  circu- 
lation. Eight  months  after  operation  the 
gland  was  of  normal  size  and  consistency.  In 
1909  Borst  and  Enderlen-*  attempted  homo- 
transplantation of  the  thyroid-parathyroid 
gland  complex  by  vascular  anastomosis  using 
dogs  and  goats  in  their  experiments  but  were 
unsuccessful  in  their  attempts.  Goodman-^ 
in  1916,  carried  out  a series  of  experiments  in 
dogs  in  which  he  performed  both  autotrans- 
plantation and  homotransplantation  of  the 
whole  thyroid  and  parathyroids  by  direct  vas- 
cular anastomosis.  He  was  successful  with 
autotransplantation  of  the  thyroid  gland  in  2 
instances  but  was  unsuccessful  in  a single  in- 
stance of  homotransplantation.  However,  and 
this  may  be  significant,  he  noted  3 instances 
where  the  parathyroids  persisted  in  viable 
form  after  homotransplantation  of  the  whole 
thyroid  gland  in  which  there  was  complete 
autolysis  of  the  thyroid  gland  but  apparent 
preservation  of  the  parathyroids.  In  1919, 
Kawamura-”  working  at  the  Mayo  Clinic  car- 
ried out  a series  of  experiments  in  dogs  in 
which  the  entire  organ  was  transplanted  by 
means  of  vascular  anastomoses  using  the 
technique  of  anastomosis  as  recommended  by 
Carrel  and  Guthrie.  Kawamura  found  that 


EXPERIMENTAL  TRANSPLANTATION  OF  PARATHYROIDS 
BY  VASCULAR  ANASTOMOSIS  IN  ANIMALS 


Name  Date 

Carrel  and  Guthrie 1905 

Borst  and  Enderlen 1909 

Goodman  1916 

Kawamura  1919 

Jordan,  Foster,  Gyorkey -1958 


Results 

Successful  autotransplantation  of  thyroid — para- 
thyroid ( dogs ) . 

Unsuccessful  homotransplantation  in  dogs  and 
goats. 


Successful  autotransplantation. 
Unsuccessful  homotransplantation. 

(dogs)  (noted  persistence  parathyroids). 

Successful  autotransplantation  (21^  hrs. ) 
Unsuccessful  homotransplantation  (dogs) 

88%  successful  autografts  in  dogs. 


Figure  4 


SEPTEMBER  I960— VOL.  30,  NO.  3 


121 


HOMOTRANSPLANTATION  BY  VASCULAR  ANASTOMOSIS 


autotransplantation  of  the  entire  thyroid 
gland  could  be  carried  out  and  good  function 
obtained  even  after  the  circulation  had  been 
interrupted  for  as  long  as  IV2  hours,  but  that 
all  attempts  at  homotransplantation  failed  to 
demonstrate  any  function  in  the  gland. 

Jordan,  Foster  and  Gyorkey-^  reported  in 
1958  on  their  experiments  on  dogs  regarding 
autotransplantation  of  parathyroid  tissue. 
They  came  to  the  conclusion  that  free  auto- 
grafts of  parathyroid  tissues  were  unsuccess- 
ful when  placed  in  the  millipore  diffusion 
chamber.  When  free  autografts  were  put  in- 
to the  sheath  of  the  axillary  vein  25%  were 
successful;  into  the  sterno  thyroid  muscle 
30%  were  successful  but  when  the  whole 
thyroid-parathyroid  complex  was  autotrans- 
planted  by  vascular  anastomosis  88%  were 
successful. 


Hoiiiof rcws plan faf ion  by  Vascular 
Anastomosis  in  tAan 

As  far  as  I can  ascertain  Borst  and  Ender- 
len-''  (figure  5)  were  the  first  surgeons  to 
attempt  homotransplantation  of  the  whole 
thyroid-parathyroid  gland  complex  in  man 
by  vascular  anastomosis.  They  were  unsuc- 
cessful in  3 instances  in  which  the  upper  pole 
of  the  gland  was  transplanted  into  the  axilla 
or  into  the  elbow. 

However,  in  1954,  Sterling  and  Goldsmith--' 
reported  the  first  successful  homotransplant 
of  thyroid-parathyroid  in  a 28  year  old  wom- 
an. This  patient  had  had  severe  tetany  for 
11  years.  Homotransplantation  was  carried 
out  in  1952  utilizing  the  thyroid-parathyroid 
from  an  infant  and  employing  direct  vascu- 
lar anastomosis.  Sterling-*"  reported  in  1957 


PARATHYROID  GLANDS  HOMOTR AN S PLANTED  BY  VASCULAR  ANASTOMOSIS 


Author 

Year 

Age 

Sex 

Duration 
of  tetany 
(years) 

Site  of 
transplant 

Result 

Post -op 
Medication 

Follow-up 

Borst  & Enderlen 

1909 

X 

X 

X 

Axilla 

Failure 

X 

X 

X 

X 

X 

Elbow 

Failure 

X 

X 

X 

X 

X 

Axilla 

Failure 

X 

X 

Sterling  & Goldsmith 

1954 

28 

F 

12 

Groin 

Success" 

1 teaspoon 

6 years 

1958 

35 

F 

15 

Rectus 

Success 

‘Ca  during  1 

3 years 

36 

F 

14 

Groin 

Success j 

menstr. 

2 1/?  years 

43 

X 

23 

Groin 

Failure 

X 

X 

Jordan,  Foster,  Curd 

1958 

36 

M 

8 

Groin 

Success 

1 -4gms 

oral  Ca/day 

14  months 

Nicks,  R. 

1958 

38 

F 

8 

Groin 

Failure 

X 

6 months 

27 

F 

8 

Groin 

Failure 

X 

2 years 

Conway,  Nickel,  Smith 

1958 

43 

F 

11/2 

Groin 

Failure 

X 

5 months 

Watkins,  Haynes,  Adams 

1959 

24 

M 

2 

Groin 

Success 

None 

4 years 

58 

F 

17 

Groin 

? 

Daily  Ca  PO 

5 months 

39 

F 

16 

Groin 

? 

Igm/dayCa 

PO 

5 months 

Nickel,  Conway,  Smith 

1960 

44 

F 

4 

Groin 

Failure 

X 

15  months 

Figure  5 


122 


J.  M.  A.  ALABAMA 


HOMOTRANSPLANTATION  BY  VASCULAR  ANASTOMOSIS 


— five  years  later — that  the  patient  had  re- 
quired no  medication  since  operation  except 
for  small  doses  of  calcium  during  menstrua- 
tion. Radioactive  Iodine  was  identified  at 
the  site  of  the  transplant.  In  addition,  Ster- 
ling3"  reported  2 other  successful  homo- 
transplants in  humans  and  a single  failure  in 
whom  two  unsuccessful  attempts  were  made 
to  transplant  whole  glands  by  vascular  anas- 
tomosis. In  all  of  Sterling’s  patients  the 
homograft  was  taken  from  infants  ranging 
in  age  from  prematurity  to  21  months.  The 
vessels  in  the  groin  of  the  recipient  were  used 
in  each  case.  Jordan,  Foster  and  Gyorkey-' 
reported  two  successful  homotransplantations 
of  thyroid-parathyroid  gland  by  vascular 
anastomosis  in  humans.  In  each  case  the  re- 
quirement for  parathyroid  replacement  ther- 
apy was  significantly  reduced  but  no  evi- 
dence of  thyroid  function  was  present  in  eith- 
er patient.  Nicks-^’  reported  that  he  has 
homotransplanted  the  whole  thyroid-para- 
thyroid complex  in  man  on  2 occasions  but 
that  in  each  case  the  patient  again  required 
replacement  therapy  at  the  end  of  12  months. 

Gnilorybov'^-  has  reported  2 successful 
cases  of  homografts  of  thyroid-parathyroid  in 
humans  utilizing  a modification  of  the  vascu- 
lar pedicle  technique  in  which  only  the  arte- 
rial anastomosis  was  performed  and  the  ve- 
nous components  were  permitted  to  drain  in- 
to the  tissues  until  the  venous  circulation  was 
re-established  spontaneously.  Gnilorybov 
failed  to  include  pertinent  data  in  his  report. 

Finally,  Watkins,  Haymes  and  Adams’^ 
have  recently  reported  on  3 patients  in  whom 
homografts  of  the  entire  thyroid-parathyroid 
gland  from  infants  were  carried  out  employ- 
ing a modification  of  the  techniques  so  far 
used.  These  workers  dissect  out  a block  of 
pretracheal  tissue  containing  thyroid  and 
parathyroid  glands  in  continuity  with  the 
great  vessels  requiring  anastomosis.  This 
simplifies  the  procedure  and  allows  end-to- 
end  or  end-to-side  anastomosis  of  large  ves- 
sels in  the  groin  of  the  recipient. 

The  patient  herein  reported  (figure  6)  is 
a 44  year  old  female  who  underwent  total 
thyroidectomy  and  right  radical  neck  dissec- 


Patient  A. M ,9,  4d  years 


! 1 ' . 1 i i i : I I ; ■ i 

iO  ?0  » iO  ?0  10  ?0  >0  10  ?0  >0  10  20  X>  30  iO  20  30 

April.  10^6  May  SepI,  19W  Oct  April,  l‘>58  Msv.  1958 


Figure  6 

tion  in  1956  for  papillary  adenocarcinoma  of 
the  thyroid  with  metastases  to  cervical  and 
mediastinal  lymph  nodes.  Shortly  following 
this  procedure  she  developed  tetany.  Replace- 
ment therapy  consisted  at  first  of  Calcium 
Gluconate  intravenously,  parathormone  and 
Vitamin  D.  Calcium  by  mouth  was  inef- 
fectual because  of  an  under-lying  ulcerative 
colitis  for  which  a resection  of  the  colon  with 
ileosigmoidostomy  had  been  performed  in 
1955.  Several  types  of  calcium  preparations, 
concentrated  Vitamin  D and  parathyroid  ex- 
tracts were  tried.  Only  Calcium  Gluconate 
intravenously  and  intramuscularly  was  ef- 
fective in  preventing  the  development  of 
tetany.  It  became  necessary  to  administer 
calcium  every  other  day. 

In  September,  1957,  approximately  18 
months  following  thyroidectomy,  the  patient 
underwent  transplantation  of  the  whole  thy- 
roid-parathyroid gland  complex. The  donor 
was  an  1800  gram  premature  infant  who  had 
lived  only  2 days.  The  donor’s  blood  was  Rh 
positive  B and  the  recipient’s  was  Rh  positive 
A.  The  patient’s  cells  were  compatible  with 
the  donor’s  serum.  The  gland  was  transplant- 
ed to  the  groin  of  the  recipient  and  anasto- 
mosis carried  out  between  the  carotid  artery 
of  the  graft  and  the  lateral  circumflex  artery 
of  the  recipient.  The  3 venous  connections 
and  the  remaining  carotid  artery  of  the  graft 
were  then  anastomosed  to  suitable  venous 
channels  of  the  recipient.  Following  this  pro- 


SEPTEMBER  I960— VOL.  30,  NO.  3 


123 


HOMOTRANSPLANTATION  BY  VASCULAR  ANASTOMOSIS 


cedure,  and  although  the  incision  became  in- 
fected, the  patient’s  calcium  intake  require- 
ments were  greatly  reduced  for  a period  of 
approximately  4 months  during  which  time 
she  required  only  occasional  doses  of  calcium. 
She  then  relapsed  rapidly  to  her  former  status 
requiring  calcium  intravenously  or  intra- 
muscularly every  day.  It  should  be  noted  that 
radioactive  iodine  uptake  studies  revealed  3% 
uptake  over  the  operative  area  10  days  post- 
operative and  6'7r  uptake  3 months  post-oper- 
ative. 

With  the  return  of  her  symptoms  it  was  de- 
cided to  implant  a free  homograft  of  parathy- 
roid tissue.  Accordingly,  in  April,  1958, 
adenomatous  parathyroid  tissue  was  trans- 
planted. This  tissue  was  taken  from  an  adult 
suffering  from  hyperparathyroidism  due  to 
an  adenoma  of  the  parathyroid  gland  and  was 
obtained  under  sterile  precautions  at  opera- 
tion and  then  grown  in  tissue  culture  for  a 
period  of  14  days.  Graded  increments  of  the 
patient’s  serum  were  then  added  to  the  tissue 
culture  according  to  the  method  of  Gaillard’^ 
in  his  reported  successful  free  homografts. 
Eight  bits  of  parathyroid  adenoma  were  im- 
planted in  the  pectoralis  muscle  and  eight 
were  implanted  in  the  rectus  muscle.  There 
was  no  discernible  improvement  in  the  pa- 
tient’s condition  following  this  second  at- 
tempt at  homografting  aside  from  the  short 
period  of  bed  rest  associated  with  the  opera- 
tion. 

The  first  homograft  of  the  thyroid-parathy- 
roid complex  had  been  complicated  by  a 
wound  infection.  But,  in  spite  of  this,  the  pa- 
tient seemed  to  respond  favorably  for  a 
period  of  3 months.  It  was,  therefore,  elected 
to  try  this  procedure  again.  Accordingly,  in 
October,  1958,  this  was  carried  out.  Follow- 
ing the  death  of  a 2 day  old  infant  the  entire 
thyroid-parathyroid  complex  including  the 
aortic  arch  and  superior  vena  cava  were  re- 
moved. This  part  of  the  procedure  was  com- 
pleted approximately  41/2  hours  after  death. 
The  aortic  arch  of  the  graft  was  then  anasto- 
mosed to  the  left  lateral  circumflex  artery  in 
the  recipient’s  groin  (figure  7)  and  the  left 
innominate  vein  of  the  graft  anastomosed  to 


Figure  7 


the  long  saphenous  vein  at  the  sapheno- 
femoral  junction  in  the  recipient.  This  type 
of  anastomosis  has  distinct  advantages  over 
the  first  type  employed  in  this  patient.  The 
vessels  are  larger  and  only  two  anastomoses 
are  necessary.  Following  the  completion  of 
the  anastomoses  there  were  vigorous  pulsa- 
tions in  the  graft  and  blood  could  be  seen 
coursing  through  it  into  the  venous  circula- 
tion. Pulsations  in  the  graft  could  be  felt  up 
to  the  time  of  discharge  24  days  later.  During 
this  period  she  required  no  specific  calcium 
therapy  whatever.  Thereafter,  she  required 
no  supplemental  calcium  therapy  other  than 
her  dietary  intake  until  January,  1959,  a 
period  of  approximately  2 months.  Then  she 
rapidly  relapsed  to  her  former  status  and  now 
again  requires  approximately  10  cc.  of  Cal- 
cium Gluconate  parenterally  every  day. 

Discussion 

It  is  plain  from  the  evidence  submitted  that 
autotransplantation  of  parathyroid  tissue 
both  experimentally  and  clinically  can  be  an- 
ticipated with  a fair  degree  of  certainty. 
However,  successful  homotransplantation  of 
parathyroid  tissue  either  in  the  experimental 
animal  or  in  the  human  is  fraught  with  un- 
certainty. One  is  entitled  to  ask  what  is  the 
justification  for  attempts  at  homografting  of 
parathyroid  tissue.  None  of  the  methods 
whereby  free  bits  of  parathyroid  tissue  are 


124 


J.  M.  A.  ALABAMA 


HOMOTRANSPLANTATION  BY  VASCULAR  ANASTOMOSIS 


homotransplanted  whether  by  the  method  of 
Halsted,  Stone  or  Algire,  has  produced  a suc- 
cessful homograft  that  is  functioning  perma- 
nently. Each  method  has  exponents  who 
claim  successful  homografts  or  improvement 
in  the  patient’s  post-operative  status  as  com- 
pared with  his  pre-operative  status  but  no 
patient  can  be  produced  who  has  unequivocal 
evidence  of  permanent  function  following  the 
implantation  of  free  homografts. 

Several  of  the  patients  who  have  had  homo- 
grafts of  parathyroid  tissue  by  vascular  anas- 
tomosis have  shown  clinical  improvement 
following  the  graft.  All  but  one,  however, 
require  some  replacement  therapy.  Recently, 
the  single  apparently  successful  homograft 
by  vascular  anastomosis  was  studied  and 
careful  calcium  balance  calculations  perform- 
ed. The  evidence  seems  conclusive  that  this 
graft  is  not  functioning. 

We  agree  with  Murray^''”'  that  it  is  necessary 
to  establish  rigid  criteria  for  the  evaluation 
of  parathyroid  transplants.  These  criteria 
should  include:  1)  the  demonstration  of 

tetany  when  replacement  therapy  is  with- 
drawn prior  to  operation,  2)  calcium  balance 
studies  which  confirm  the  presence  of  com- 
plete and  permanent  function  of  the  homo- 
graft, 3)  histological  evidence  of  a function- 
ing homograft,  and  4)  return  of  tetany  after 
removal  of  the  graft.  Of  course,  some  of  these 
criteria  are  impractical.  It  would  not  be  de- 
sirable to  remove  a homograft  which  was 
thought  to  be  functioning  and  thereby  repro- 
duce the  very  condition  for  which  so  much 
time  and  effort  has  been  expended.  It  would 
be  sufficient  to  demonstrate  that  the  with- 
drawal of  a replacement  therapy  prior  to  op- 
eration resulted  in  tetany  and  that  calcium 
balance  studies  before  and  after  homograft- 
ing demonstrate  permanent  function  of  the 
parathyroid  homograft. 

In  conclusion,  it  should  be  mentioned  that 
there  is  some  evidence  that  glandular  trans- 
plants react  differently  from  other  tissues.  It 
has  been  shown  for  example  that  ovarian 
transplants  react  quite  differently  from  skin 
when  homografts  are  transplanted  in  animals. 
Jacob-5  et  al  feel  that  endocrine  tissues  do 


not  follow  the  usual  laws  of  host-rejection  of 
homografted  tissues.  Furthermore,  Good- 
man-‘  noted  in  his  experiments  that  when 
homografts  of  the  whole  thyroid-parathyroid 
complex  were  transplanted  in  animals  that 
the  parathyroids  would  sometimes  remain  in- 
tact although  the  thyroid  tissue  became  auto- 
lyzed.  It  is  also  possible,  as  suggested  by  Hal- 
sted,that  the  hypoparathyroid  state  itself 
increases  the  chance  of  successful  homotrans- 
plantation of  parathyroid  tissue. 

S/i  m mary 

In  summary  it  may  be  stated  that  parathy- 
roid autografts  whether  by  free  transplanta- 
tion or  by  vascular  anastomosis  are  success- 
ful in  experimental  animals.  Homografts  in 
the  experimental  animal,  on  the  other  hand, 
are  uniformly  unsuccessful. 

In  man,  homografts  of  parathyroid  tissue 
whether  by  tree  transplant  or  by  vascular 
pedicle  react  in  an  unpredictable  manner  so 
that  rigid  criteria  are  necessary  for  proper 
evaluation  of  such  homografts. 

REFERENCES 

1)  Sandstrom,  I.  V.  Uber  eine  neue  Druse  beim 
Menschen  und  bei  verschiedenen  Sangetiere, 
Schmidt’s  Jahr,  1880,  Stockholm,  Sweden. 

2)  Vassale,  G.  and  Generali,  E.  Arch  ital.  di 
bioL,  Turin,  1895,  25:  459,  1896  26,  61,  1900,  33:  154. 

2a)  MacCallum,  W.  G.  and  Voegtlin,  C.  Bull 
J.  H.  Hosp,  Balt.,  1908,  29:  91,  J.  Exper.  Med., 
1909,  11:  118. 

3)  Halsted  Collected  Papers. 

4)  Payr,  E.  Transplantation  von  Schulddrus- 
engewebe  in  die  Milz,  Arch  V.,  Klin,  Chir,  80:  730, 
1030,  1906. 

5)  Dunphy,  J.  E.  and  Keeley,  J.  L.  Experi- 
mental studies  in  transplantation  of  the  adrenal 
gland.  Surgery,  8:  105,  1940. 

6)  Shambaugh,  P.  Autotransplantation  of  the 
parathyroid  gland  in  the  dog;  Evaluation  of  Hal- 
sted’s  Law  of  Deficiency,  Arch  Surgery,  32:  709, 
1936. 

7)  Braunwald,  N.  S.,  Hufnagel,  C.  A.  The  ef- 
fect of  the  site  of  transplantation  and  the  pres- 
ence of  glandular  deficiency  on  the  success  of 
thyroid  autografts.  Surgery,  43:  428,  1958. 

8)  Stone,  H.,  Owings,  J.  and  Gey,  G.  O.  Trans- 
plantation of  living  grafts  of  thyroid  and  parathy- 
roid glands,  Ann.  Surg.,  100:  613,  1934. 


SEPTEMBER  I960 — VOL.  30,  NO.  3 


125 


HOMOTRANSPLANTATION  BY  VASCULAR  ANASTOMOSIS 


9)  Pinkus,  H.  K.,  Maddock,  W.  G.,  Coller,  F.  A. 
Clinical  and  experinaental  observation  on  parathy- 
roid transplants,  Transactions  of  the  Am.  Ac.  of 
Goitre,  p.  65,  1937. 

10)  Houghton,  B.  C.,  Klassen,  K.  P.,  Curtis,  G. 
M.  Studies  in  human  parathyroid  gland  trans- 
plantation, Ohio  State  M.  J.,  35:  505,  1939. 

11)  Peycelon,  R.,  Latarjet,  M.,  Guillet,  E.  On 
the  treatment  of  post-operative  tetany  by  a para- 
thyroid graft,  Lyon  Chir.,  42:  467,  1947. 

12)  Bland,  W.  H.,  Chessen,  A.  L.,  Crow,  J.  B. 
Parathyroid  gland  transplantation.  No.  Carolina 
M.  J.,  11:  501,  1950. 

13)  Gaillard,  P.  J.  Transplantation  of  culti- 
vated pai'athyroid  gland  tissue  in  man;  Ciba  Sym- 
posium; Preservation  and  transplantation  of 
normal  tissues.  Little,  Brown  & Co.,  Boston,  Mass., 
P.  100-6,  1954. 

14)  Escamilla,  R.  F.,  Kempe,  C.  H.,  Craine,  J., 
Goldman,  L.  and  Gordon,  G.  S.  Preliminary  ex- 
periences with  transplants  of  cultured  parathy- 
roid tissue  in  hypoparathyroidism,  Ann.  Int.  Med., 
46:  649,  1957. 

15)  Snyderman,  R.  K.  Personal  Communica- 
tion. 

16)  Reid,  M.  R.  and  Ransohoff,  J.  Intravascu- 
lar parathyroid  grafts,  AM.  J.  M.  Sci.,  206:  731, 
1943. 

17)  Braunwald,  N.  S.  and  Hufnagel,  C.  A.  Mod- 
ification of  homotransplantation  by  growth  in 
tissue  culture,  Surg.,  43:  501,  1958. 

18)  Liddle,  E.  B.,  Willenstein,  G.  J.,  Swain,  H. 
Studies  in  autotransplantation  of  thyroid  and 
adrenal  gland  in  dogs,  Surgical  Forum,  4:  701, 
1953. 

19)  Algire,  G.  H.,  Weaver,  J.  M.,  Prehn,  R.  T. 
Growth  of  cells  in  Vitro  in  diffusion  chambers; 
Survival  of  homografts  in  immunized  mice,  J.  Nat. 
Cancer  Inst.,  15:  493,  1954. 

20)  Brooks,  John  R.  Millipore  diffusion  cham- 
ber boosts  homograft  use,  Scope  Weekly,  Jan.  4, 
1960. 

21)  Swan,  H.,  Hallin,  R.,  Callaghan,  P.,  Welch, 
K.,  Friedman,  V.  Observations  on  function  and 
morphology  of  parathyroid  tissue  homografts  in 


the  dog  using  millipore  chambers,  Halsted  Labora- 
tory of  Experimental  Research,  Univ.  of  Colorado, 
School  of  Medicine,  ACS  meeting,  Atlantic  City, 
N.  J.,  Sept.,  1959. 

22)  Stone,  H.  B.,  Eyring,  J.  F.  Technique  notes 
for  tissue  culture  and  transplantation  experiments, 
Transplantation  Bui.,  4:  17,  1957. 

23)  Carrel,  A.,  Guthrie,  C.  C.  Extirpation  et 
replantation  de  la  grande  thyroide  avec  revision 
de  la  circulation,  Compt.  rend,  Soc.  biol.  59:  413, 
1905. 

24)  Goodman,  C.  The  transplantation  of  thy- 
roid glands  in  dogs.  Am.  J.  M.  Sci.,  152:  348,  1916. 

25)  Jacob,  S.  W.,  Gowing,  D.,  Dunphy,  J.  E. 
Transplant  of  tissues.  Am.  J.  Surg.  98:  55,  July, 
1959. 

26)  Kawamura,  K.  Studies  of  organ  trans- 
plantation of  the  thyroid  gland  with  intact  blood 
supply,  J.  Exper.  Med.,  30:  45,  1919. 

27)  Jordan,  G.  L.,  Foster,  R.  P.,  Gyorkey,  F. 
Transplantation  of  parathyroid  glands.  Plastic  & 
Reconstr.  Surg.  22:  393,  1958. 

28)  Borst  & Enderlen.  Uber  transplantation 
von  gefassen  und  gauzen  organen,  Deutsch.  L. 
Chir.,  1909,  XCIX,  54. 

29)  Sterling,  J.  A.,  Goldsmith,  R.  Total  trans- 
plant of  thyroid  gland  using  vascular  anastomosis, 
35:  624,  1954. 

30)  Sterling,  J.  A.  Transplantation  of  homol- 
ogous thyroid  and  parathyroid  glands.  Trans- 
plantation Bui.,  5:  52,  1958. 

31)  Nicks,  R.  Transplantation  of  thyroid-para- 
thyroid glands  for  chronic  hypoparathyroid  dis- 
ease, Plastic  & Reconstr.  Surg.,  23:  424,  1959. 

33)  Gnilorybov,  T.  E.  Homoplastic  transplanta- 
tion of  glands  of  internal  secretion  to  vascular 
pedicle,  Vestnik.  Akad.  Med.  Nank  SSSR.  ii(2): 
35,  1956. 

34)  Conway,  H.,  Nickel,  W.  F.,  Smith,  J.  W. 
Homotransplantation  of  thyroid  and  parathyroid 
glands  by  vascular  anastomosis.  Plastic  & Reconstr. 
Surg.  23:  469,  1959. 

35)  Murray,  J.  E.  Plastic  & Reconstr,  Surg., 
22:  369,  1958. 


126 


J.  M.  A.  ALABAMA 


The  Managemenl  Of  School  Phobia 
By  The  Family  Physician 


JOHN  D.  ELMORE.  M.  D. 
Birmingham,  Alabama 


Almost  any  pediatrician  or  general  prac- 
titioner has  answered  an  early  morning  sum- 
mons to  treat  a child’s  gastric  upset  or  head- 
ache, only  to  find  on  arrival  a youngster 
abounding  in  physical  health,  a mother  regis- 
tering mingled  anxiety,  relief,  and  annoyance 
— and  himself  confronted  with  an  incipient 
or  full-blown  case  of  school  phobia.  And  the 
handling  of  a child’s  sudden,  apparently  in- 
explicable dread  of  school  accompanied  by 
somatic  symptoms  illustrates  forcibly  the  key 
position  of  the  family  physician  in  today’s 
medical  picture.  School  phobia  is  by  no 
means  a simple  and  clear-cut  entity.  Its  on- 
set is  usually  masked  by  somatic  illness  of  a 
psychogenic  nature.  Sometimes  a child  is 
able  to  say  that  he  is  afraid  but  usually  is  un- 
able to  define  his  fears.  Almost  invariably 
the  evidence  of  anxiety  is  disguised  as  a slight 
physical  illness,  with  vomiting,  headache, 
cramps,  or  diarrhea,  which  permits  absence 
from  school.  If  allowed  to  remain  away, 
these  children  recover  remarkably  from  any 


Dr.  Elmore  is  a graduate  of  Tulane  University- 
School  of  Medicine  and  is  a member  of  the  Frank 
Kay  Clinic,  Birmingham,  Alabama.  He  is  an  as- 
sistant professor  of  psychiatry  at  The  Medical  Col- 
lege of  Alabama. 


somatic  complaints  shortly  after  the  time  for 
roll-call  has  passed,  and  on  Saturdays,  Sun- 
days, and  holidays  they  are  usually  tree  of 
symptoms. 

If  not  handled  promptly  and  effectively, 
complications  in  the  form  of  secondary  gains 
raise  further,  sometimes  insurmountable,  bar- 
riers to  successful  treatment  or  may  psycho- 
logically cripple  the  child  permanently.  The 
presenting  symptoms  and  even  the  psycho- 
dynamics of  the  emotional  disturbance  under- 
lying this  reaction  are  so  nearly  uniform  that, 
given  a few  clues,  the  general  medical  man 
without  specialized  psychiatric  training  can 
manage  the  problem  with  a dispatch  and 
authority  which  will  greatly  facilitate  res- 
toration to  normal  with  simple  management 
measures,  or  greatly  ease  the  path  of  the  psy- 
chiatrist should  psychiatric  referral  be  found 
necessary. 

The  onset  of  school  phobia  is  usually  abrupt 
and  dramatic,  coming  as  a surprise  to  parents 
and  teachers  alike.  Generally  these  are  chil- 
dren of  average  or  superior  intelligence  who 
have  liked  and  done  well  in  their  studies. 
The  reaction  tends  to  be  more  common  in 
boys  than  in  girls.  It  may  range  from  re- 
luctance toward  attending  school  to  actual 


SEPTEMBER  I960— VOL.  30,  NO.  3 


127 


MANAGEMENT  OF  SCHOOL  PHOBIA 


panic  and  often  follows  some  upsetting  inci- 
dent— most  frequently  a minor  one  such  as 
an  embarrassment  or  scolding — in  the  school 
setting. 

Because  of  the  somatic  complaints,  such  as 
vomiting,  headache,  cramps  or  diarrhea,  a 
physician  is  usually  consulted,  and  a series  of 
examinations  may  be  performed.  By  the 
time  it  is  discovered  there  is  nothing  or- 
ganically wrong,  the  child  may  have  been 
absent  from  school  for  a considerable  period 
of  time,  and  his  eventual  return  becomes  in- 
creasingly difficult  in  equal  ratio  to  the 
amount  of  time  spent  away.  The  youngster 
is  embarrassed  about  his  absence,  he  is  be- 
hind in  his  work,  and  whatever  the  minor, 
anxiety-provoking  incident  may  have  been 
tends  to  be  greatly  magnified  beyond  its  real 
significance. 

Too  often  this  experience  which  the  child 
— and  perhaps  the  parent — feels  to  be  the 
precipitating  or  explanatory  factor  is  in  reali- 
ty a manifestation  of  anxiety  over  separation 
from  the  parent  and  a rationalization  for  the 
gratification  of  dependency  needs.  The  ne- 
cessity for  getting  the  child  back  to  school 
promptly  can  be  appropriately  stressed  only 
if  both  the  handling  physician  and  the  par- 
ents understand  that  school  phobia  is  a clini- 
cal variant  of  the  neurotic  syndrome,  separa- 
tion anxiety.  Actually  the  child’s  fear  is  not 
connected  with  anything  in  the  school  situa- 
tion but  is  an  expression  of  a pathologic  de- 
gree of  anxiety  aroused  by  having  to  leave 
his  parent  when  he  goes  to  school. 


Phobia  or  T riiancy? 

It  is  important — and  fairly  simple — to  dis- 
tinguish school  phobia  from  common  truancy, 
with  which  it  is  sometimes  confused.  These 
phobic  children  go  home — go  straight  home 
and  stay  there — in  contrast  to  the  more  ad- 
venturous truants  who  avoid  both  home  and 
school.  Further,  the  former  group  shows 
none  of  the  anti-social  traits,  such  as  lying 
and  stealing,  which  are  frequently  features 


in  the  delinquent  behavior  of  truants.  In  an 
early  study  of  truancy,’  Partridge  listed  other 
differential  characteristics:  The  phobic  chil- 
dren do  not  dodge  simple  difficulties  or  revolt 
against  circumstances,  and  there  is  generally 
no  lack  in  their  material  environment  which 
could  point  to  their  behavior  being  a compen- 
sating mechanism.  Most  importantly,  he 
noted  the  bearing  of  maternal  overattach- 
ment on  school  phobia,  thus  pointing  to  its 
underlying  cause,  which  is,  quite  simply,  a 
mutually  over-dependent,  even  symbiotic, 
relationship  between  a child  and  parent  (usu- 
ally the  mother)  with  undue  reliance  on  the 
other’s  close  physical  presence  to  conceal 
anxiety. 

The  dynamics  of  separation  anxiety,  con- 
siderably over-simplified,  form — as  they  do 
in  many  other  neurotic  disturbances — a vici- 
ous circle:  A mother’s  over-permissiveness, 
often  springing  from  unconscious  rejection 
of  her  child,  leads  to  increased  demands  from 
the  youngster,  with  resulting  ambivalent 
feeling  in  the  mother  of  resentment  of  his 
added  demands,  guilt  over  her  hostile  feel- 
ings, and  back,  full  cycle,  to  over-protection 
as  an  act  of  restitution  to  the  child  and  reas- 
surance to  herself.  These  mothers  are  un- 
sure of  their  maternal  capacities,  and,  by  al- 
ternating between  excessive  expressions  of 
love  and  hostility,  they  create  corresponding 
insecure  and  ambivalent  emotions  of  hostility, 
guilt,  and  over-solicitousness  in  the  child. 
Some  writers-’  trace  such  a mother’s  anxi- 
ous handling  of  her  parental  role  to  an  un- 
resolved dependency  relation  with  her  own 
mother  and  feel  that  neurotic  characteristics 
in  other  members  of  the  family — which  they 
seemed  to  find  to  be  always  present — point  to 
separation  anxiety  as  being  what  could  al- 
most be  called  an  ‘inherited  neurosis’.  I have 
not  observed,  as  has  been  suggested,”  that 
these  children  are  invariably  more  subject 
to  other  phobias  than  normal  children,  al- 
though compulsive  character  traits  are  usual- 
ly present. 


128 


J.  M.  A.  ALABAMA 


MANAGEMENT  OF  SCHOOL  PHOBIA 


The  Doctor’s  Wait'mg  Room — A 
T beater 

For  the  physician  without  extensive  psy- 
chiatric knowledge,  there  is  a better  means 
of  recognizing  these  neurotic  patterns  than  in 
an  exhaustive  inventory  of  symptoms.  It 
has  been  observed'*  that  the  conviction  we 
have  about  our  knowledge,  whether  it  is 
guessed,  supposed,  or  known  for  certain — 
makes  a difference  in  the  effective  use  we 
make  of  it.  We  are  most  likely  to  be  certain 
of  what  we  have  seen  for  ourselves.  The 
doctor’s  waiting-room  provides  a theater 
where  an  observant  practitioner  may  witness 
directly  a vivid  portrayal  of  the  spoken  and 
unspoken  communication  between  a parent 
and  child,  and  that  inconsistency  between, 
words  and  behavior  which  is  operative  in  the 
genesis  of  separation  anxiety. 

When  a youngster  and  his  mother  are  asked 
to  come  individually  into  the  doctor’s  office, 
one  may  watch  played  out  in  overt  behavior, 
at  an  actual  moment  of  separation,  emotions 
which  are  factors  in  this  neurotic  involve- 
ment of  parent  and  child.  One  sees  the  sub- 
tle way  in  which,  characteristically,  the  moth- 
er unwittingly  fosters  dependency.  If  the 
child  is  a little  hesitant  about  entering  alone, 
the  mother  is  apt  to  offer  such  ineffectual  and 
non-reassuring  encouragement  as,  “He  won’t 
really  hurt  you,”  or,  “He  is  just  going  to  talk 
to  you,”  thus  reenforcing  the  image  of  her- 
self as  a strong,  indispensable  symbol  of  safe- 
ty and  protection,  although  ostensibly  she  is 
pushing  him  away.  It  becomes  easier  to  un- 
derstand the  basic  situation  when  one  ob- 
serves that  separation  is  as  difficult  for  the 
parent,  because  of  her  own  morbid  depend- 
ence, as  it  is  for  the  youngster.  When  asked 
to  leave  the  child  in  the  waiting  room,  a moth- 
er may  look  rather  longingly  and  anxiously 
over  her  shoulder  as  she  goes  into  the  office, 
and  often  she  cannot  make  any  positive  mo- 
tion away  from  him.  The  line  of  communica- 
tion between  the  unconscious  of  a mother  and 
that  of  her  off-spring  is  a particularly  sensi- 
tive one.  Sensing  his  mother’s  anxiety  and 
unconscious  wish  to  have  him  dependent,  the 


child  responds  with  appropriate  regressive 
behavior.  But  when  he  chngs  to  mother,  if 
you  look  carefully  you  will  see  that  she  is 
also  clinging  to  him.  The  child’s  behavior 
is  then  seen  to  be  a mirror  image  of  his  par- 
ent’s and  one  may  gain  a clearer  insight  into 
his  apparent  fear  of  school.  Reflecting  the 
hostile-dependent  attitude  of  his  mother,  the 
youngster  has  projected  this  hostility,  which 
he  cannot  accept  as  part  of  his  feeling  to- 
ward a beloved  parent,  onto  some  part  of  the 
school  situation.  By  thus  ridding  himself  of 
an  unwanted  feeling,  he  is  able — indeed  is 
obliged  to — cling  more  closely  to  the  protec- 
tive maternal  object,  stifling  his  natural 
strivings  toward  independence. 

Clearly,  the  child’s  continued  remaining  at 
home  allows  this  mutually  strangling  rela- 
tionship to  flourish  in  its  already  rich  cul- 
ture until  major  therapy  may  be  required 
to  hack  through  and  release  the  pair.  Al- 
though the  silver  cord  cannot  be  severed  im- 
mediately by  a few  words  of  advice,  it  can 
and  must  be  made  to  stretch  sufficiently  to 
allow  reestablishment  of  regular  school  at- 
tendance. Often  the  problem  of  school  phobia 
appears  only  after  a child  has  been  out  of 
school  for  some  time  because  of  a severe 
physical  illness,  surgery,  or  hospitalization. 
Sibling  rivalry  can  also  be  a prominent  ele- 
ment when  there  is  a younger  child  of  pre- 
school age  who  remains  at  home  with  the 
mother.  Or,  as  has  been  seen,  an  upsetting 
experience  at  school  may  be  seized  upon  as 
a rational  excuse  for  indulging  dependent 
behavior.  In  all  cases,  the  secondary  gains 
achieved  by  remaining  out  of  school  tend  to 
prolong  the  reaction.  The  child  obtains  re- 
enforcement of  dependency  gratification  by 
receiving  more  of  his  mother’s  attention  and 
solicitude,  he  gets  even  in  his  competition 
with  his  sibling  rival,  and  he  becomes  the 
center  of  interest  in  the  household.  Thus, 
children  who  may  have  previously  been 
obedient,  even  passive,  are  apt  to  become  ag- 
gressive and  threatening — in  short,  dominat- 
ing tyrants,  provoking  further  resentment, 
guilt,  indulgence — the  beginning  again  of  the 
endless  circle. 


SEPTEMBER  I960— VOL.  30,  NO.  3 


129 


MANAGEMENT  OF  SCHOOL  PHOBIA 


Back  T ()  School 

Most  authorities  agree  with  Klein  '*  that  the 
most  immediate  need  is  to  get  the  youngster 
back  in  school  on  any  level  which  he  can 
tolerate.  It  may  be  helpful  to  have  a parent 
go  with  the  child  for  the  first  few  days  or  even 
to  stay  in  the  building  for  a bit.  Often  it  is 
easier  for  the  father  to  do  this,  as  he  is  less 
involved  emotionally  and  can  be  more  effec- 
tively firm  and  forceful.  Initially,  the  child 
may  be  required  only  to  spend  some  part  of 
the  day  in  the  school  building  rather  than  in 
the  classroom  itself.  The  important  thing  at 
first  is  to  get  him  away  from  home  and  into 
the  school  building.  If  it  is  necessary  to  do 
this  gradually,  first  for  only  part  of  the  day 
at  a time,  this  should  be  the  decision  of  the 
physician  and  parents,  and  not  presented  as 
a concession  or  bribe  to  the  child.  Threats 
or  punishment  should  not  be  invoked,  but 
rather  firm  insistence,  administered  as  calmly 
as  possible,  should  be  observed.  The  sooner 
the  child  realizes  he  is  expected  to  resume 
normal  school  activities  the  better. 

It  is  impossible  to  overemphasize  that  this 
apparently  heartless  procedure  will  not  cause 
the  youngster  to  become  psychotically  ill,  will 
not  drive  him  into  a breakdown,  will  not 
traumatize  him  emotionally.  However,  the 
handling  physician  must  expect  to  meet 
strong  resistance  from  both  mother  and  child. 
Fortunately,  these  children  recognize  the 
peculiar  and  undesirable  quality  of  their 
symptoms  and  consciously  want  to  control 
their  fears  and  return  to  school.  Another 
favorable  factor  is  the  child’s  relative  health. 
Case  studies  reveal  that  in  grade-school  chil- 
dren the  symptom  appears  in  the  context  of 
an  otherwise  fairly  sound  personality,  with 
other  facets,  such  as  peer  relationships,  re- 
maining intact.' 

The  mother  is  likely  to  be  torn  between  a 
sincere  willingness  to  allow  the  child’s  return 
and  her  inability  to  let  go  of  him  and  of  her 
own  childish  dependency  gratifications.  How- 
ever, most  of  these  parents  prove  to  be  cap- 
able of  further  maturation  and  are  able  to 
respond  to  advice  offered  in  a sympathetic 


and  accepting  manner.  Also,  they  feel  suf- 
ficiently trapped  to  want  help.  Coolidge,  re- 
porting on  clinic  management  of  school 
phobia,^  observed  that  almost  every  mother 
expressed  an  obsessional  doubt  of  her  ability 
to  be  a good  mother  in  the  directly  stated  or 
implied  words,  “I  do  not  know  whether  I did 
right  or  wrong.”  Here,  the  handling  phy- 
sician may  advantageously  rely  upon  a basic 
concept  of  psychotherapy:  “How  do  I know 
what  I think  until  I hear  what  I say?”  By 
being  allowed  to  verbalize  their  fears  and 
needs  to  a respected,  understanding  person, 
many  of  these  women  may  be  led,  by  a mix- 
ture of  firm  guidance  and  heavy  support,  to 
an  eventual  recognition  of  their  inconsistent 
and  adnormal  demands  upon  a child  and  the 
part  they  have  played  in  his  illness.  Factors 
contributing  to  a mother’s  unconscious  re- 
jection of  her  child  are  as  varied  as  the 
myriad  family  emotional  constellations.  In 
view  of  the  limited  time  and  scope  available 
to  him,  the  general  practitioner  would  be  wise 
not  to  delve  too  deeply  into  these  basic  is- 
sues. The  most  useful  task  he  can  perform 
is  to  supply  heavy  reassurance  to  the  parents, 
encouraging  them  toward  a decision  to  re- 
turn the  child  to  school.  It  is  remarkable 
how  far  this  initial  step  can  go  toward  alter- 
ing the  fundamental  neurotic  structure  of  a 
child-parent  relationship — but  not  amazing 
when  one  reflects  that  hitherto  the  child’s 
greatest  need  has  been  just  such  firm  and 
consistent  handling  from  the  significant 
adults  in  his  environment. 

Cooperation  At  School 

The  child’s  teacher  and  principal  should  be 
alerted  not  to  send  him  home  although  he 
may  be  exhibiting  symptoms  of  anxiety  or 
somatic  upset.  A simple,  uninvolved  explana- 
tion, that  the  child  is  suffering  from  anxiety 
and  that  this  makes  him  feel  sick,  is  usually 
sufficient  to  assure  the  teacher  she  will  not 
be  injuring  the  child  physically  or  emotional- 
ly. Quite  often  the  youngster,  through  the 
mechanism  of  displacement,  has  projected 
toward  his  teacher  all  the  repressed  resent- 


130 


J.  M.  A.  ALABAMA 


MANAGEMENT  OF  SCHOOL  PHOBIA 


ment  felt  for  his  parent.  Such  a teacher  must 
be  freed  of  any  sense  of  blame  for  the  child’s 
disturbance,  in  order  that  she  may  treat  him 
with  love  and  understanding  while  insisting 
that  he  conform  to  accepted  school  standards. 
By  a consistent  blend  of  sympathy  and  firm- 
ness, she  may  be  able  to  supply  the  youngster 
the  sense  of  security  he  lacks  at  home. 

A few  notes  of  caution  remain  to  be 
sounded. 

If  a child  becomes  comfortable  in  the  school 
situation,  one  may  be  reasonably  assured  that 
what  seemed  to  be  a severe  emotional  dis- 
turbance was  in  fact  a fairly  benign  one. 
This  agrees  with  the  findings  of  follow-up 
studies  conducted  at  a number  of  child  guid- 
ance clinics  which  showed  that  relief  of  the 
presenting  symptom  of  children’s  emotional 
problems  allowed  the  child  an  extremely 
good  chance  of  continuing  thereafter  a nor- 
mal personality  development.*^*  However,  re- 
ports of  case  histories  have  drawn  a sharp 
distinction  between  two  personality  types 
which  emerge  in  school  phobia.  While  among 
younger  children  the  process  tends  to  be  lim- 
ited and  encapsulated,  among  adolescents  the 
emotional  disturbance  is  apt  to  be  of  such 
long  standing  that  personality  changes  have 
become  fixed,  or  ‘characterological’,  and  the 
anxiety  has  spread  to  envelop  other  reality 
areas  of  their  lives. '■  The  latter  cases 

are  far  more  resistant  to  treatment  and  usual- 
ly require  long-term  therapy  by  an  experi- 
enced psychiatrist. 

Even  with  a young  child,  a fairly  regular 
check  should  be  made  to  determine  whether 
the  youngster,  having  adjusted  satisfactorily 
to  the  school  situation,  has  not  merely  shifted 
his  unresolved  anxieties  into  another  equally 
undesirable  channel.  The  family  physician 
may  do  this  unobtrusively  by  a casual  ‘symp- 
tom inventory’  when  the  child,  or  some  mem- 
ber of  his  family,  comes  to  the  office  for 
routine  medical  care.  Does  Johnny  have 
trouble  sleeping,  eating,  getting  along  with 
other  children  or  grown-ups?  Or  with  diges- 
tion, unusual  fears,  nervousness,  thumbsuck- 
ing, overactivity,  or  sex?  Does  he  show  signs 

SEPTEMBER  I960— VOL.  30,  NO.  3 


of  excessive  daydreaming,  temper  tantrums, 
crying,  lying,  stealing,  destructiveness,  or  re- 
jection of  school?  The  frequency,  duration, 
and  severity  of  such  symptoms  are  fairly  re- 
liable and  positive  criteria  for  determining 
the  degree  of  emotional  disturbance  in  a 
young  child. 

Similarly,  a careful  watch  should  be  kept 
on  the  mother  and  other  children  in  the  fam- 
ily; when  a mother  is  thwarted  in  her  ab- 
normal dependent  relationship  with  one 
child,  she  may  simply  involve  another, 
younger  child  in  the  same  neurotic  pattern. 
Here  again,  the  family  physician  is  in  a 
uniquely  favorable  position  to  follow  up  the 
results  of  his  suggestions  and  to  assess  how 
deep-seated  the  neurosis  may  have  been. 


Somatic  Diseases — Psychogenic 
Illnesses 

The  success  of  preventive  medicine  in  con- 
trolling somatic  diseases  has  given  impetus  to 
the  search  for  methods  of  early  diagnosis  and 
prevention  of  psychogenic  illnesses.  The  in- 
creased activity  of  recent  years  in  the  field  of 
mental  health  has  shown  how  far-reaching 
and  intensive  efforts  must  be  in  order  to  pro- 
duce any  noticeable  effect. There  is  a pres- 
ent woeful  shortage  of  practicing  psychia- 
trists, and  these  are  kept  fully  occupied  with 
the  existing,  more  serious  emotional  and  men- 
tal problems.  If  the  scope  of  preventive  med- 
icine is  to  be  broadened  to  include  successful 
preventive  psychiatry,  much  of  that  success 
must  depend  upon  the  general  practitioner’s 
willingness  to  resume  his  ancient  role  of  fam- 
ily counselor,  armed  with  the  newer  insights 
which  psychiatric  research  provides. 

Some  of  the  most  accessible  and  fertile 
areas  for  a beginning  are  the  emotional  crises 
of  early  childhood.  Dr.  Leon  Eisenberg 
writes:  “What  is  required,  above  all,  to  help 
troubled  children  and  their  parents  is  sincere 
interest  and  a willingness  to  listen;  a faith  in 
the  ability  of  most  people,  given  a chance,  to 
work  out  their  own  solutions,  and  reasonable 
confidence,  without  arrogance,  in  one’s  own 

13  1 


MANAGEMENT  OF  SCHOOL  PHOBIA 


judgment.”''*  Most  of  us  agree  that  the  fami- 
ly physician,  by  devoting  as  much  considera- 
tion to  signals  of  emotional  distress  as  to 
signs  of  endemic  and  epidemic  ills,  may  be- 
come the  one  “compleat  physician”  capable 
of  treating  the  “compleat  patient.” 

REFERENCES 

1.  Partridge,  J.  D.  (1939):  Cited  by  Warren, 
W.:  Acute  Neurotic  Breakdown  in  Children  With 
Refusal  to  Go  to  School.  Arch.  Dis.  Childhood 
23:  266-272  (Dec.)  1948. 

2.  Johnson,  A.  M.,  and  others:  School  Phobia. 
Am.  J.  Orthopsychiat.  11:  702-711  (Oct.)  1941. 

3.  Talbot,  M.:  Panic  in  School  Phobia.  Am.  J. 
Orthopsychiat.  27:  286-295  (April)  1957. 

4.  Suttenfield,  V.:  School  Phobia:  A Study  of 
Five  Cases.  Am.  J.  Orthopsychiat.  24:  368-380 
(April)  1954. 

5.  Perkins,  G.:  Discussion  of  paper  by  Eisen- 

berg,  L.:  School  Phobia:  A Study  in  the  Communi- 
cation of  Anxiety.  Am.  J.  Psychiat.  114:  712-718 
(Feb.)  1958. 


6.  Klein,  E.:  The  Reluctance  to  Go  to  School. 
Psychoanal.  Study  of  the  Child  1:  263-279,  1945. 

7.  Coolidge,  J.  C.,  and  others:  Neurotic  Crisis 
or  Way  of  Life.  Am.  J.  Orthopsychiat.  27:  296-306 
(April)  1957. 

8.  Waldfogel,  S.,  Coolidge,  J.  C.,  and  Hahn,  P. 

B. :  The  Development,  Meaning  and  Management 
of  School  Phobia.  Am.  J.  Orthopsychiat.  27:  754- 
780  (Oct.)  1957. 

9.  Levy,  D.  M.  (1947),  Witmer,  Helen  (1933), 
and  Gardner,  G.  (1953)  Quoted  by  Glidewell,  J. 

C. ,  and  others:  Behavior  Symptoms  in  Children 

and  Degree  of  Sickness.  Am.  J.  Psychiat.  114:  47- 
53  (July)  1957. 

10.  Waldfogel,  S.^ 

11.  Eisenberg,  L.:  School  Phobia:  Diagnosis, 

Genesis  and  Clinical  Management.  Pediat.  Clin. 
North  America,  Aug.  1958.  pp.  645-666. 

12.  Kubie,  L.  (1948):  Cited  by  Lindemann,  E.: 
The  Use  of  Psychoanalytic  Constructs  in  Preven- 
tive Psychiatry.  Psychoanal.  Study  of  the  Child 
7:  429-448,  1952. 

13.  Eisenberg,  L.:  The  Parent-Child  Relation- 
ship and  the  Physician.  A.  M.  A.  Am.  J.  Dis.  Child. 
91:  153-157  (Feb.)  1956. 


132 


J.  M.  A.  ALABAMA 


Long  Term  Anticoagulant  Therapy 
In  Office  Practice— Practical  Application 


J.  J.  KIRSCHENFELD,  M.  D. 
Montgomery,  Alabama 


This  paper  on  the  practical  aspects  of  long 
term  anticoagulant  therapy  in  office  practice 
is  the  latest  in  a series  of  articles  designed  to 
explore  the  usefulness  and  the  techniques  of 
important  procedures  carried  out  in  the  prac- 
tice of  internal  medicine.  Earlier  published 
articles  dealt  with  the  prevalence  and  sig- 
nificance of  anemia  and  the  diagnosis  of 
anemia,!-’  1.3,  u,  15  intestinal  parasitism,!'*  and 
estimation  of  pulmonary  function.!^ 

The  value  of  the  anticoagulant  drugs  in 
thromboembolic  disease  has  been  amply  con- 
firmed by  the  work  of  Wright,  Nelson,  Bark- 
er, Hines  and  numerous  others.'-  2.  3.  9 There 
is  general  agreement  that  the  anticoagulants 
have  been  life  saving  by  preventing  pulmon- 
ary and  peripheral  embolism.  Due  to  the  fact 
that  more  stable  thromboplastins  and  control 
plasma  are  commercially  available,  the  de- 
termination of  the  prothrombin  time  is  now  a 


Dr.  Kirschenfeld  is  a graduate  of  New  York  Uni- 
versity School  of  Medicine  and  has  practiced  in- 
ternal medicine  in  Alabama  since  1947.  He  is  an 
assistant  professor  of  clinical  medicine  at  The  Med- 
ical College  of  Alabama.  The  author  is  indebted 
to  Mr.  H.  H.  Tew,  B.  S.,  for  performing  all  labo- 
ratory work  and  helping  with  collection  of  the 
data  and  charts. 


relatively  simple  procedure  that  can  be  per- 
formed with  considerable  accuracy  in  any 
doctor’s  office.  The  indications  and  contra- 
indications for  anticoagulant  therapy  have 
been  well  outlined  in  numerous  studies  and 
are  now  generally  accepted. 

The  prophylactic  exhibition  of  an  antico- 
agulant drug  is  recommended  in  the  follow- 
ing situations: ® 

1.  Following  vascular  surgery. 

2.  Following  pelvic  or  major  abdominal 
surgery. 

3.  Following  splenectomy. 

4.  Following  any  major  operation  where 
there  is  a history  of  previous  thrombosis  with 
or  without  embolism. 

5.  In  any  situation  where  prolonged  bed- 
rest will  be  required;  especially  where  there 
are  leg  varicosities  and/or  where  there  is  any 
slowing  of  the  flow  of  blood,  such  as  in  con- 
gestive heart  failure. 

6.  In  chronic  auricullar  fibrillation  due  to 
rheumatic  heart  disease  especially  when  con- 
version is  being  attempted. 

The  anticoagulants  are  employed  thera- 
peutically in  the  following  situations: 


SEPTEMBER  I960— VOL.  30,  NO.  3 


133 


ANTICOAGULANT  THERAPY  IN  OFFICE  PRACTICE 


1.  Acute  thrombophlebitis  or  phlebo- 
thrombosis.  (This  distinction  is  rather  aca- 
demic.) 

2.  Coronary  thrombosis. 

3.  Unquestioned  cerebral  thrombosis. 

4.  Mesenteric  thrombosis. 

5.  Retinal  thrombosis. 

6.  Congestive  failure  that  is  going  down- 
hill without  obvious  cause;  this  may  be  due 
to  multiple  pulmonary  emboli. 

7.  Any  other  form  of  venous  thromboem- 
bolic disease  such  as  migratory  thrombophle- 
bitis, post-partum  or  post-traumatic  phlebitis 
or  carcinomatosis. 

8.  In  occlusive  arterial  disease. 

9.  Acute  arterial  embolization,  especially 
with  associated  diabetes  mellitus,  thrombo- 
angitis  obliterans  and  frost  bite. 

The  contra-indications  to  anticoagulant 
therapy  are  quite  definite; 

1.  Hemorrhagic  diseases. 

2.  Gastro-intestinal  ulcers. 

3.  Significant  liver  disease. 

4.  Moderate  to  severe  renal  disease. 

5.  Severe  dietary  deficiencies,  especially  a 
deficiency  of  Vitamin  K. 

The  sole  complication  of  anticoagulant 
therapy  is,  of  course,  hemorrhage  and  the 
propensity  for  this  depends  on  the  individual 
anticoagulant.  Familiarity  with  and  constant 
use  of  one  anticoagulant  enables  the  physician 
to  prevent  this  complication. 

Heparin  was  recognized  as  the  first  anti- 
coagulant practical  for  clinical  use  in  1936. 
Three  years  later.  Link  synthesized  the 
coumarin  compound  Dicoumarol.  This  was 
first  employed  clinically  in  1940.  The  latter 
drug  is  still  widely  used  but  has  certain  dis- 
advantages. Another  class  of  anticoagulants, 
the  indaniones,  are  available  but  are  more 
toxic  than  the  coumarins  and,  therefore,  not 
as  popular.  Heparin  is  an  excellent  antico- 
agulant exhibiting  several  other  useful  prop- 
erties, such  as  reduction  of  fat  in  the  serum 
and  reduction  of  platelet  adherence;  however, 
it  must  be  given  parenterally  and  its  duration 


of  effect  is  quite  short.  Furthermore,  it  is 
extremely  expensive.  Therefore,  heparin  is 
primarily  used  for  the  induction  of  anticoagu- 
lant therapy  pending  achievement  of  thera- 
peutic prothrombin  blood  levels  from  the 
oral  drugs.  The  properties  of  an  ideal  anti- 
coagulant would  be  as  follows:" 

1.  Effective  orally  as  well  as  parenterally. 

2.  Rapid  onset  of  action. 

3.  Satisfactory  therapeutic  index  and  free- 
dom from  untoward  side  effects. 

4.  No  cumulative  action  or  toxicity  from 
prolonged  use  in  ambulatory  patients. 

5.  Predictable  quantitative  relations  to 
dose  and  anticoagulant  effect. 

6.  Anticoagulant  activity  not  requiring 
daily  laboratory  control. 

7.  Prompt  cessation  of  the  effect  when  ad- 
ministration is  stopped. 

8.  Low  cost. 

Warfarin  (Coumadin®)  approaches  this 
ideal.'’’  '■  ® It  can  be  given  orally  or  intra- 
venously with  complete  absorption  by  either 
route.  The  effect  of  a single  dose  usually  lasts 
several  days  and  the  latent  period  is  approxi- 
mately 16  hours  with  the  therapeutic  range 
achieved  in  approximately  24  hours.  Peak 
effect  of  Warfarin  is  obtained  between  the 
second  and  third  day.  The  sole  reason  for  its 
parenteral  use  occurs  in  situations  where  the 
patient  cannot  tolerate  medication  by  the  oral 
route.  The  therapeutic  effect  is  maintained 
nicely  with  daily  Coumadin®  dosage  and  the 
prothrombin  level  returns  to  normal  within 
3 days  following  cessation  of  therapy.  There 
are  no  toxic  effects;  the  sole  complication  be- 
ing hemorrhage.  The  hemorrhagic  complica- 
tion is  rapidly  reversible  with  Vitamin  K. 
The  drug  is  soluble,  stable  and  fairly  inex- 
pensive. 

Many  published  reports  concerning  Cou- 
madin® '*•  ’■  have  indicated  that  a loading 
dose  of  50-75  milligrams,  either  orally  or  in- 
travenously, produced  a therapeutic  hypo- 
prothrombinemia  in  approximately  24  hours 
and  that  due  to  its  prolonged  action,  the 
therapeutic  level  was  maintained  on  a daily 


134 


J.  M.  .A.  ALABAMA 


ANTICOAGULANT  THERAPY  IN  OFFICE  PRACTICE 


dosaga  varying  from  4 to  10  milligrams. 
Hemorrhages  occurred  in  5%  of  patients  and 
were  of  a minor  degree. 

Rigorous  control  of  the  therapeutic  action 
of  any  anticoagulant  drug  requires  regular 
prothrombin  analyses.  The  accepted  method 
is  Quick’s  one  stage  prothrombin  determina- 
tion. Essentially,  the  clotting  time  of  the 
plasma  is  measured  after  optimal  amounts 
of  thromboplastin  and  calcium  are  provided. 
The  prothrombin  time  so  determined  is  the 
minimal  interval  that  elapses  before  a macro- 
scopic clot  results  from  the  conversion  of 
prothrombin  to  thrombin.  This  reflects  the 
amount  of  prothrombin  evolved  together 
with  the  velocity  of  its  evolution.  The  validi- 
ty of  the  method  rests  upon  the  assumption 
that  the  velocity  of  the  prothrombin  con- 
version to  thrombin,  as  well  as  the  latter’s 
conversion  of  fibrinogen  to  fibrin,  is  a meas- 
ure solely  of  prothrombin  concentration. 
Other  factors,  which  in  practice  are  not  im- 
portant, may  affect  the  Quick  one  stage 
method.  A depressed  fibrinogen  level  may 
cause  a decreased  prothrombin  activity  de- 
spite a normal  prothrombin  content.  Similar- 
ly, a low  labile  factor  level  can  prolong  the 
prothrombin  time.  Antithrombins  in  various 
forms  and  amounts  may  be  present,  inacti- 
vating at  least  a portion  of  the  thrombin  that 
is  generated  and  this  would  reduce  the  con- 
version of  fibrinogen  to  fibrin.  These  inhibi- 
tors are  still  not  well  defined. 

The  most  important  factor,  of  course,  is  the 
potency  of  the  thromboplastin  utilized.  A 
thromboplastin  giving  a prothrombin  time 
of  more  than  11  to  13  seconds  with  normal 
plasma  may  not  be  potent.  Most  commercial 
thromboplastins  are  lyophilized  and  potent 
but  when  placed  in  solution  may  deteriorate 
rather  rapidly.  The  potency  may  also  vary 
from  batch  to  batch.  Therefore,  it  is  essen- 
tial that  the  extract  be  checked  against  nor- 
mal pooled  control  plasma.  (These  are  now 
available  commercially.)  A curve  relating 
the  prothrombin  time  with  the  prothrombin 
activity  should  be  constructed  with  each 
batch  of  thromboplastin.  From  these  curves 
the  observed  prothrombin  time  is  translated 

SEPTEMBER  I960— VOL.  30,  NO.  3 


into  prothrombin  activity,  expressed  as  a 
percentage.  Moreover,  if  the  actual  curve 
approaches  the  contour  of  the  theoretical 
standard  curve,  the  uniformity  of  the  throm- 
boplastin is  assured.  (The  diluent  should  be 
prothrombin-free  plasma  and  not  saline  since 
the  latter  dilutes  out  the  accessory  factors.) 

Prothrombin  time  determinations  of  pa- 
tients on  oral  anticoagulant  therapy  may 
fluctuate  rapidly.  After  any  given  dose  of 
anticoagulant,  80'/  of  the  plasma  prothrom- 
bin disappears  within  24  hours.  The  remain- 
ing 20%  is  still  sufficient  to  give  a relative- 
ly normal  prothrombin  time.  The  difference 
in  prothrombin  time  between  plasma  with 
lOO*/  prothrombin  and  that  with  20'%  is  only 
slight.  However,  in  the  latter  case,  if  more 
drug  is  given  the  prothrombin  time  may  de- 
cline suddenly.  Therefore,  in  inducing  hypo- 
prothrombinemia,  it  is  important  to  give  the 
loading  dose  and  then  wait  several  days  and 
re-evaluate.  Furthermore,  the  response  of 
patients  will  vary  with  differences  in  weight, 
rate  of  absorption  of  drug  and  individual  va- 
riations in  liver  function.  It  has  been  de- 
termined that  heavy  menstrual  periods,  use 
of  salicylates,  heavy  drinking,  heavy  smoking, 
obesity,  hormone  therapy  and  even  racial 
characteristics  will  affect  the  response  to 
anticoagulant  drugs.  Therefore,  there  can 
be  no  substitute  for  consistent,  precise  and 
regular  prothrombin  time  determinations.  It 
is  imperative  that  anticoagulant  therapy  not 
be  utilized  unless  accurate  prothrombin  time 
determinations  are  available. 

The  overriding  concern  in  anticoagulant 
therapy  is  the  question  as  to  what  constitutes 
a safe  and  therapeutic  level.  This,  of  course, 
will  not  be  the  same  in  short  term  intensive 
therapy  and  long  term  prophylactic  therapy. 
In  the  former  situation,  a prothrombin  time 
of  30  to  40  seconds  (two  to  three  times  the 
normal  prothrombin  time)  or  20%  of  pro- 
thrombin activity,!  is  considered  adequate. 
(This  is  of  course  true  for  someone  with  a 
normal  hemostatic  mechanism  but  may  not 
be  for  a patient  with  vascular  degenerative 
disease,  with  hereditary  semi-permeability 
of  the  vessels  or  with  an  intrinsic  coagulation 

135 


ANTICOAGULANT  THERAPY  IN  OFFICE  PRACTICE 


disorder.)  On  the  other  hand,  in  ambulatory 
patients,  on  long  term  therapy,  a prothrom- 
bin time  of  20  to  30  seconds  (IV2  to  2 times 
normal)  is  considered  safe  and  adequate.  The 
question  of  therapeutic  efficiency  at  these 
levels  still  remains  to  be  proven  after  much 
more  experience  is  acquired. 

The  feasibility  and  the  safety  of  long  term 
anticoagulant  therapy  on  an  out-patient  basis 
in  office  practice  has  been  questioned.  There 
have  been  very  few  studies  of  well  controlled 
anticoagulant  therapy  over  a long  period  of 
time  in  such  a situation.--  We  thought  it 
would  be  of  interest  to  evaluate  our  results 
during  the  past  several  years  in  regards  to  a 
series  of  patients  exhibiting  various  diseases, 
who  have  been  ambulatory  and  who  have 
been  maintained  on  Coumadin®  over  a period 
ranging  up  to  3 years.  The  series  is  ad- 
mittedly small,  however,  the  cases  have  been 
carefully  chosen,  the  indications  for  antico- 
agulant therapy  were  definite  and  accepted, 
and  the  data  has  been  rather  complete.  This 
series  of  23  office  patients  was  controlled  by 
virtue  of  regular  prothrombin  determinations 
in  our  own  office  laboratory.  It  is  offered 
in  the  hope  that  physicians  in  private  prac- 
tice will  have  no  hesitation  in  using  antico- 
agulant drugs  provided  the  facilities  are  ade- 
quate and  the  patients  cooperative. 

Procedure 

Materials  and  equipment: 

light  source 

3 — 0.1  ml  pipettes  calibrated  “to  contain” 

1 — water  bath  at  37.5  degrees  Centigrade 

1 —  stop  watch 

2 —  test  tubes  approximately  9 x 75  mm. 

Thromboplastin*  and  calcium  chloride  so- 
lution (0.0125  molar) 

0.1  M sodium  oxalate 

15  ml  centrifuge  tube  (calibrated) 

Centrifuge 

0.5  ml  pipet 

*We  have  found  Solu-Plastin®  (Schieffelin 
and  Company)  to  be  stable  if  obtained  direct- 


ly from  manufacturer  and  kept  under  refrig- 
eration. It  is  not  necessary  to  perform  a 
standard  determination  each  day,  however, 
a weekly  standard  check  is  desirable.  The 
quantity  of  thromboplastin  and  calcium 
chloride  supplied  is  sufficient  for  100  determi- 
nations. 

Technique 

Exactly  one  half  milliliter  of  0.1  M sodium 
oxalate  solution  is  placed  in  the  15  ml  centri- 
fuge tube.  Approximately  5 ml  of  venous 
blood  is  drawn  cleanly  from  the  antecubital 
vein  with  a minimum  of  stassis.  The  blood  is 
added  directly  to  the  centrifuge  tube  contain- 
ing the  oxalate  solution  and  the  level  brought 
up  to  the  5 ml  mark  precisely.  A stopper  is 
inserted  and  the  contents  are  inverted  twice. 
The  tube  is  immediately  placed  in  the  centri- 
fuge and  spun  for  five  minutes  at  approxi- 
mately 2000  rpm. 

While  the  plasma  is  being  separated,  0.1  ml 
of  the  thromboplastin  solution  is  pipetted  in- 
to one  of  the  small  test  tubes.  One-tenth  ml 
of  the  calcium  chloride  solution  is  added.  A 
small  portion  of  the  plasma  is  removed  from 
the  centrifuged  blood  and  placed  in  another 
small  tube.  Both  the  plasma  and  the  throm- 
boplastin calcium  solutions  are  placed  in  the 
water  bath  (37.5°  C)  for  approximately  three 
minutes. 

A light  source  that  will  give  an  oblique 
light  is  necessary  for  observing  the  end  point. 
We  use  a small  fluorescent  light  mounted  un- 
der a reagent  shelf.  The  stop  watch  and  a 
paper  napkin  or  gauze  square  is  placed  in  a 
convenient  position  under  the  light  source. 
A 0.1  ml  pipet  (or  0.2  ml  calibrated  at  0.1)  is 
rubbed  vigorously  with  a gauze  square  to 
warm  by  friction.  One-tenth  milliliter  of  the 
patient’s  plasma  is  withdrawn  from  the  tube 
in  the  water  bath.  The  pipet  containing  the 
plasma  is  carefully  inserted  in  the  tube  con- 
taining the  thromboplastin  mixture  until  the 
tip  of  the  pipet  is  about  one  centimeter  below 
the  surface  of  the  mixture.  The  exact  position 
of  the  stop  watch  is  noted  and  the  plasma  is 
blown  into  the  thromboplastin  calcium  chlo- 


136 


J.  M.  A.  ALABAMA 


ANTICOAGULANT  THERAPY  IN  OFFICE  PRACTICE 


TABLE  1 

AGE  RANGE  AND  SEX  OF  TWENTY-THREE  PATIENTS  ON 
LONG  TERM  ANTI-COAGULANT  THERAPY 


Age  Range 

No.  Male 

- 

No.  Female 

Total 

30-40 

2 

0 

2 

40-50 

2 

1 

3 

50-60 

4 

0 

4 

60-70 

7 

3 

10 

70  + 

2 

2 

4 

Total 

17 

6 

23 

TABLE  2 

DISTRIBUTION  OF  DIAGNOSES  AMONG  23  PATIENTS 
ON  LONG  TERM  ANTICOAGULANT  THERAPY 


Diagnosis  Number 

Cerebral  thrombosis,  recurrent 4 

Thrombophlebitis,  acute  and  cerebral  thrombosis  . — 2 

Thrombophlebitis,  recurrent _ 2 

Myocardial  infarction 8 

Coronary  insufficiency  with  ischemia 3 

Cerebral  embolus  due  to  auricullar  fibrillation  (rheumatic  heart  disease) 2 

Pulmonary  embolus 2 


ride  mixture.  The  stop  watch  is  immediately 
started  and  the  contents  of  the  tube  is  mixed 
by  twirling.  The  tube  is  wiped  dry  with  the 
paper  napkin  and  placed  under  the  light 
source,  tilted  back  and  forth  and  observed  for 
the  clot  formation.  The  stop  watch  is  held 
in  one  hand. 

If  the  tube  is  held  in  the  right  position  un- 
der the  light,  the  beginning  of  the  clot  will 
be  observed  as  a white  translucence  on  the 
surface  of  the  mixture.  Immediately  there- 
after, the  clot  will  be  observed  and  the  stop 
watch  stopped  and  the  time  noted.  In  our 
laboratory  we  prefer  the  direct  observation 
to  the  use  of  a wire  loop  in  detecting  the  end 
point  and,  with  a little  practice,  the  tech- 
nician can  learn  to  manipulate  the  tube  and 
stop  watch  without  any  loss  of  time.  Using 
this  technique,  we  have  been  able  to  dupli- 


cate the  determination  with  an  accuracy  of 
plus  or  minus  one  second. 

We  have  found  that  the  prothrombinn  time 
will  become  gradually  prolonged  as  the  blood 
is  kept  at  room  temperature  following  veni- 
puncture. However,  this  is  negligible  within 
2-3  hours.  This  makes  it  possible  to  draw  the 
blood  in  the  home  of  the  patient  and  trans- 
port it  to  the  laboratory  where  it  can  be  an- 
alyzed within  a few  hours. 

Discussion  and  Results 

The  age  range  and  sex  of  the  23  patients  on 
prolonged  anticoagulant  therapy  reveals  a 
uniform  distribution  (Table  1).  The  diag- 
noses and  the  indications  for  exhibition  of  the 
anticoagulant  drugs  are  quite  varied  (Table 
2) . The  duration  of  anticoagulant  therapy  in 


SEPTEMBER  I960— VOL.  30,  NO.  3 


137 


ANTICOAGULANT  THERAPY  IN  OFFICE  PRACTICE 


TABLE  3 

LENGTH  OF  TIME  ON  ANTI-COAGUI,ANT  THERAPY 


Time  on  Tiierapy  Number  Patients 

2- 3  Months.- — - . ..  . . . 2 

3- 6  Months.  ...  . ..  . 1 

6-9  Months . . 4 

9-12  Months _..  ..  5 

1- 2  Years.. 8 

2- 3  Years 2 

Over  3 Years  . 1 


TABLE  4 

AVERAGE  FREQUENCY  OF  PROTHROMBIN  TIME  DETERMINATIONS  ON 
TWENTY  THREE  PATIENTS  ON  LONG  TERM  ANTICOAGULANT  THERAPY 


Stage  of  Therapy 

Frequency  of  Determmation 

1st  week 

4.6  per  week 

2nd  week 

2.8  per  week 

3rd  week  

- 1.7  per  week 

4th  we<=“k 

1.5  per  week 

2nd  month 

3.5  per  month 

3rd  month 

...2.3  per  month 

after  3rd  month  

1.5  per  month 

these  23  patients  extended  from  2 months  to 
3 years  (Table  3).  Three  were  on  therapy 
for  2 to  6 months,  20  for  more  than  six  months 
while  11  were  on  therapy  for  more  than  1 
year.  One  patient  remained  anticoagulated 
longer  than  3 years.  You  will  note  (Table 
4)  that  during  the  first  week  of  therapy  the 
prothrombin  determinations  were  performed 
an  average  of  4 to  5 times  and  then  the  fre- 
quency fell  to  approximately  3 times  during 
the  second  week,  two  times  the  third  week 
and  slightly  more  than  once  a week  during 
the  fourth  week  of  therapy.  After  the  first 
month,  prothrombin  determinations  were 
performed  every  two  weeks  and  after  the 
third  month,  approximately  once  to  twice  a 
month.  Many  patients,  after  stabilization  on 
therapy  for  several  months,  were  well  con- 
trolled with  one  determination  every  four 
to  six  weeks.  We  found  that  once  an  individ- 


ual was  stabilized,  the  dose  remained  quite 
fixed  and  the  prothrombin  time  remained  at 
a constant  level  (Table  4). 

To  assess  the  degree  of  control  of  the  thera- 
peutic hypoprothrombinemia,  we  assumed 
that  a therapeutic  level  maintained  90  to  100 
per  cent  of  the  time  was  excellent,  80  to  90 
per  cent  was  good  and  70  to  80  per  cent  was 
fair.  A therapeutic  level  maintained  less 
than  70%  of  the  time  was  considered  poor, 
(Table  5).  It  was  assumed  that  the  thera- 
peutic range  was  one  and  a half  to  three  times 
normal.  One  half  of  the  patients,  therefore, 
were  under  excellent  control,  one  third  were 
under  good  control,  and  15%  were  under  fair 
control  while  only  four  patients  out  of  the 
23  were  not  well  controlled  (maintained  a 
therapeutic  prothrombin  level  less  than  70% 
of  the  time).  In  short,  19  of  the  23  patients 
were  well  controlled  on  a regime  of  pro- 


ne 


J.  M.  A.  ALABAMA 


ANTICOAGULANT  THERAPY  IN  OFFICE  PRACTICE 


TABLE  5 

DEGREE  OF  CONTROL  OF  LONG  TERM  ANTICOAGULANT 
THERAPY  ON  TWENTY  THREE  PATIENTS 


Degree  oj  Control 

Number  Patients 

Excellent  (90-100%  of  time)* 

Good  (80-90%  of  time)* 

Fair  (70-80%  of  time)*.. 

Poor  (Less  than  70%  of  time)* 

— 

11 

_ 5 

3 

4 

*Prothrombin  time  in  therapeutic  range  (IVz-S  times  normal) 


thrombin  determinations  approximately  four 
weeks  apart. 

The  scattergram  (Figure  1)  very  clearly 
demonstrates  that  the  great  majority  of  the 
prothrombin  time  determinations  performed 
in  this  laboratory,  following  anticoagulant 
therapy,  lie  in  the  therapeutic  range  (II/2  to 
3 times  the  control). 

Depicted  in  another  manner  (Figure  2)  we 
note  that  more  than  50%  of  the  prothrombin 
time  determinations  were  1%  to  2V2  times 
the  control  level,  25%  of  the  determinations 


were  21%  to  3 times  the  control  and  only  a 
very  small  number  were  above  or  below 
these  levels. 

The  average  daily  Coumadin®  dosage  re- 
quired appears  to  fall  into  2 groups;  a dosage 
of  3 to  5 milligrams  per  day  and  a dosage  of 
8 to  10  milligrams  per  day.  There  are  very 
few  patients  requiring  more  or  less  than  these 
ranges.  The  courses  of  two  typical  patients 
on  prolonged  anticoagulant  therapy  are  illus- 
trated, (Figure  4 and  Figure  5).  Realizing 
that  these  determinations  have  been  spread 
over  many  months  of  therapy,  one  can  see 


70 

65 

60 

55 

50 

45 

40 

35 

30 

25 

20 

15 

10 


2 3 4 5 S 7 8 

Days  on  Therapy 


10  11  12  13  -14  15 


Figure  1.  Scattergram  showing  distribution  of  prothrombin  time  determinations  during  first  two 
weeks  of  therapy  on  23  patients. 


SEPTEMBER  I960— VOL.  30,  NO.  3 


139 


ANTICOAGULANT  THERAPY  IN  OFFICE  PRACTICE 


Prothrombin  Time  in  Seconds 
(Control  ^ 13-15  seconds) 


Figure  2.  Distribution  of  All  Prothrombin  Time 
Determinations  Performed  on  Twenty-Three  Pa- 
tients on  Long-Term  Anticoagulant  Therapy  Ex- 
pressed as  Percentages  of  Total  Determination 
Over  Period  of  3 Years. 


how  relatively  smooth  the  prothrombin  level 
is  maintained. 

In  our  series  of  23  patients,  anticoagulated 
over  this  long  period  of  time,  there  were  five 
episodes  of  bleeding;  four  were  mild  hema- 
tomas and  one  was  an  episode  of  mild  vaginal 
bleeding.  There  were  no  other  complications. 
The  patients  were  given  a typed  instruction 
sheet  containing  an  explanation  for  the  use  of 
the  drug  and  the  necessity  for  careful  dosage 
and  regular  blood  checkups.  In  addition, 
they  were  warned  of  possible  complications 
such  as  nose  bleeds,  skin  bruising,  urinary 
bleeding,  etc.  They  were  also  given  several 
5 mg.  tablets  of  Vitamin  (Mephyton®) 
and  were  instructed  to  take  two  if  bleeding 
was  severe  and  then  to  report  to  this  Clinic. 
There  were  no  episodes  of  bleeding  severe 
enough  to  require  intravenous  Vitamin  K,.  It 
is  important  to  note  that  once  Vitamin  Kj  is 
given,  it  is  rather  difficult  to  re-establish  the 
hypoprothrombinemia  for  several  days. 

The  initial  loading  dose  for  this  group  of 
patients  was  as  follows.  Twenty  of  the  pa- 


Figure  3.  Distribution  of  Average  Daily  Coumadin  Dosage  Among  Twenty  Two  Patients  on  Long- 
Term  Anticoagulant  Therapy.  (Twenty-third  patient  maintained  on  100  Milligrams  Dicoumarol  daily) 


140 


J.  M.  A.  ALABAMA 


PROrriROMBIN  TIME  IN  SECONDS  |3  PROIHROMBIN  TIIE  IN  SECONDS 


ANTICOAGULANT  THERAPY  IN  OFFICE  PRACTICE 


Figure  4.  Case  No.  1 (FG).  Prothrombin  Times  and  Coumadin®  Dosages  of  Representative  Patient 
Long  Term  Anticoagulant  Therapy 


Dai’S  of  Therapy 


Weeks  if  Therapy 


Figure  5.  Case  No.  2 (BC).  Prothrombin  Times  and  Coumadin®  Dosages  of  Representative  Patient 
on  Long  Term  Anticoagulant  Therapy 


SEPTEMBER  I960— VOL.  30,  NO.  3 


141 


23.' 


ANTICOAGULANT  THERAPY  IN  OFFICE  PRACTICE 


tients  required  75  mgs.  (intravenously  or 
orally) , 2 patients  required  50  mgs.  and  one 
required  25  mgs.  (the  latter  were  older  pa- 
tients with  some  possible  reduction  in  liver 
function.)  As  a rule,  it  can  be  postulated 
that  a 75  mg.  loading  dose  by  either  route,  is 
adequate  for  the  majority  of  patients. 

Our  procedure,  after  the  loading  dose,  was 
to  wait  48  hours  and  then  re-check  the  pro- 
thrombin time.  At  that  time  we  either  gave 
additional  medication  or  if  the  level  was 
adequate  rechecked  again  the  following  day. 
As  a rule,  the  patients  required  5 to  10  mgs. 
additionally  on  the  third  day  and  thereafter, 
were  maintained  on  an  average  of  5 to  10  mgs. 
per  day.  Since  the  tablets  are  manufactured 
in  2,  5,  7V2)  10  25  mg.  dosages,  it  is  quite 

simple  to  maintain  a patient  on  this  drug. 

In  situations  where  it  was  important  to 
have  the  patient  anticoagulated  immediately, 
we  gave  heparin  parenterally  every  4 hours 
for  several  days  and  controlled  the  coagula- 
tion level  by  the  Lee  White  method;  this  was 
discontinued  on  the  third  day  when  the  cou- 
madin  had  acheived  its  peak  effect.  It  is  es- 
sential to  remember  that  heparin  will  pro- 
long the  prothrombin  time  and  therefore,  the 
prothrombin  time  should  be  determined  four 
hours  after  the  last  dose  of  heparin  has  been 
given. 


Conclusion 

Twenty-three  patients  were  maintained  on 
Coumadin®  (Warfarin)  over  a period  rang- 
ing up  to  three  years.  The  indications  for 
anticoagulant  therapy  were  the  generally  ac- 
cepted ones,  i.e.,  thromboembolic  disease  of 
various  types.  It  was  found  that  utilizing  the 
regime  described  the  control  was  good  to  ex- 
cellent in  the  majority  of  cases  after  a loading 
dose  of  75  mg.  followed  by  an  average  main- 
tenance dosage  of  5 to  10  milligrams  of  cou- 
madin  per  day.  There  were  very  few  bleed- 
ing complications  and  none  required  cessa- 
tion of  therapy.  It  is  felt  that,  with  adequate 
laboratory  facilities,  office  anticoagulation 
over  a long  period  of  time  is  feasible. 


REFERENCES 

1.  Editorial,  Long  Term  Anticoagulant  Therapy 
After  Myocardial  Infarction,  Journal  of  the  Ca- 
nadian Medical  Association,  Volume  81,  No.  8,  Oc- 
tober, 1959. 

2.  Putnam,  William  F.:  Long  Term  Anticoagu- 
lant Therapy,  GP  Journal,  Volume  16,  No.  6,  De- 
cember, 1957. 

3.  Mink,  K.  P.;  Ikwam,  Sthmanma:  Studies  on 

4-hydroxy  Coumarins,  A Combination  of  Alpha 
Beta — Unsaturated  Ketones  with  4-hydroxy  Cou- 
marins, Journal  of  American  Chemical  Societies, 
66;  902,  1944. 

4.  Meyer,  Ovido:  Postgraduate  Medicine,  24: 

2,  August,  1958. 

5.  Nickle,  E.  S.;  Page,  S.  W.,  Jr.:  Dicumarol 

Therapy  in  Acute  Coronary  Thrombosis,  Results 
in  50  Attacks,  Journal  of  Florida  Medical  Associa- 
tion, 32:  356,  1946. 

6.  Meyer,  Ovido;  Triggs,  P.  O.;  Clatenoff,  Dallas 
V.:  Clinical  Experiences  With  Coumadin  Coagu- 
lants Warfarin  and  Warfarin  Sodium,  A.M.A. 
Archives  of  Internal  Medicine,  Volume  94,  No.  2, 
August,  1954. 

7.  Pollock,  Byron  E.:  Clinical  Experience  with 
Warfarin  (Coumadin  Sodium),  A New  Anticoagu- 
lant, Journal  of  American  Medical  Association, 
Volume  159,  No.  11,  November,  1955. 

8.  Nicholson,  Joseph  H.;  Leveltt,  Thomas,  Jr.: 
Coumadin  Sodium,  A New  Anticoagulant,  New 
England  Journal  of  Medicine,  Volume  255,  No.  11, 
September  13,  1956. 

9.  Wright,  I.  S.:  Anticoagulant  Therapy  and  the 
Treatment  of  Thromboembolic  Disease,  Postgradu- 
ate Medicine,  7:  161,  March,  1950. 

10.  Foley,  W.  T.;  Wright,  I.  S.:  Long  Term  Anti- 
coagulant Therapy  for  Cardiovascular  Disease, 
American  Journal  of  Medical  Science,  217;  136, 
February,  1949. 

11.  Goodman,  Lewis  S.;  Gillman,  Alfred:  Phar- 
macological Basis  of  Therapeutic,  Second  Edition, 
McMillan  Company,  New  York,  1955. 

12.  Kirschenfeld,  J.  J.;  Tew,  H.  H.:  Prevalence 
and  Significance  of  Anemia  As  Seen  In  A Rural 
General  Practice,  Journal  of  the  American  Medi- 
cal Association,  July  9,  1955,  Vol.  158,  pp.  807-811. 

13.  Kirschenfeld,  J.  J.:  A Simplified  Approach 
To  Anemia,  Clinical  Medicine,  Volume  V,  No.  8, 
August,  1958. 

14.  Kirschenfeld,  J.  J.;  Tew,  H.  H.:  Some 

Practical  Aspects  in  the  Management  of  the  Ane- 
mias, Journal  of  the  Medical  Association  of  State 
of  Alabama,  August,  1958. 

15.  Kirschenfeld,  J.  J.;  Tew,  H.  H.;  Anemia 
As  Seen  in  a Rural  General  Practice,  G.  P., 
November,  1957. 

16.  Kirschenfeld,  J.  J.:  Intestinal  Parasitism  in 
a Rural  Patient  Population,  GP,  March,  1959. 

17.  Kirschenfeld,  J.  J.;  Tew,  H.  H.:  A Simple 
Office  Procedure  and  Apparatus  For  Estimation 
of  Pulmonary  Function,  Journal  of  the  Medical 
Association  of  the  State  of  Alabama,  January,  1960. 


142 


J.  M.  A.  ALABAMA 


JOURNAL  EXCERPTS 


ICE  WATER  RECOMMENDED  AS 
FIRST  AID  FOR  BURNS 

Ice  water  has  been  recommended  as  the 
best  first  aid  measure  for  any  burn  covering 
up  to  20  per  cent  of  the  body. 

Dr.  Alex  G.  Shulman  of  Los  Angeles,  writ- 
ing in  a current  issue  of  the  Journal  of  the 
American  Medical  Association,  states  that  his 
experience  indicates  that,  whatever  the  sub- 
sequent management  may  be,  those  patients 
who  receive  initial  ice-water  treatment  fare 
better  than  those  who  do  not. 

Although  the  beneficial  effect  of  cold  in 
burns  has  been  sporadically  advocated  for 
many  years,  he  said,  it  has  been  studied  seri- 
ously only  in  the  past  five  years. 

Dr.  Shulman’s  investigation  began  eight 
years  ago  when  he  burned  his  own  hand  with 
boiling  grease. 

In  the  ensuing  agonizing  few  minutes  it 
seemed  logical  to  plunge  the  hand  into  a tub 
of  cold  water,  he  explained. 

Finding  that  the  pain  was  alleviated  and 
the  burn  subsequently  healed  more  rapidly 
than  expected,  he  decided  to  use  the  same 
therapy  for  his  patients. 

His  method  is  to  place  the  burned  area  im- 
mediately into  a basin  containing  tap  water, 
ice  cubes,  and  the  disinfectant,  hexachloro- 
phene.  For  burns  of  the  head,  neck,  shoulder, 
chest,  abdominal  wall  or  back,  where  immer- 
sion is  impractical,  he  applies  towels  chilled 
in  a bucket  of  ice  water. 

The  cold  treatment  is  continued  until  it  can 
be  stopped  without  return  of  pain.  The  peri- 
od ranges  from  30  minutes  to  five  hours. 

Dr.  Shulman  said  he  had  treated  150  pa- 
tients in  this  manner.  Most  of  the  burns  were 
thermal,  due  to  excessive  heat  or  cold;  but 
some  were  chemical  and  electrical  burns. 

“In  every  patient  thus  treated,  immediate, 
gratifying  relief  was  expressed  at  once,”  he 
said. 

“Whereas  pain  ordinarily  lasts  24  hours  or 
more  in  the  first-degree  burn,  relief  in  these 
patients  was  immediate;  and  the  pain  was 


almost  totally  absent  by  the  time  the  patient 
left  the  office  two  or  three  hours  later. 

“The  impression  obtained  from  our  experi- 
ence is  that,  although  the  primary  injurious 
effect  of  the  burn  has  taken  place,  the  usual 
inflammatory  process  secondary  to  the  burn 
can  be  reduced  in  degree  and,  indeed,  at  times 
reversed  by  ice-water  therapy. 

“No  infections  have  been  encountered  in 
those  patients  treated  within  one  hour  of  in- 
jury. 

“The  time  factor  between  injury  and  treat- 
ment determines  the  result.  This  treatment 
should,  therefore,  be  initiated  it  possible  by 
the  patient  or  first-aid  attendant  at  once.  This 
would  be  far  more  effective  first-aid  treat- 
ment than  the  usual  first-aid  measure  of  ap- 
plying butter  or  grease  which  will  only  have 
to  be  painfully  removed  later  by  the  attend- 
ing physician. 

“It  is  suggested  that  this  humane  and  sim- 
ple form  of  first-aid  management  of  less  ex- 
tensive burns  should  find  its  way  into  the 
thousands  of  books,  manuals,  and  pamphlets 
on  first-aid  throughout  our  nation.” 

I loort)  I 

I Annual  Session  | 

I of  the  I 

! Medical  Association  ! 

I of  the  I 

I State  of  Alabama  | 

i Hotel  Stafford  j 

I Tuscaloosa  I 

j April  27-29  | 

! 1961  1 


SEPTEMBER  I960— -VOL.  30,  NO.  3 


143 


Sditorials 


POLITICAL  PARTY  PLATFORMS 

In  this  election  year  of  1960  it  is  more  im- 
portant than  ever  that  the  medical  profession 
inform  itself  concerning  the  platforms  of  the 
two  political  parties.  The  statement  of  poli- 
cies contained  in  both  platforms  is  the  pro- 
posed mode  of  political  life  under  which  all 
of  the  citizens  of  this  country  will  live.  Al- 
though the  medical  profession  understand- 
ably has  what  is  perhaps  a keener  interest  in 
the  health  planks  of  the  platforms,  the  time 
is  long  past  when  we  as  citizens  can  interest 
ourselves  only  in  this  one  segment. 

The  State  Medical  Association  does  not  at- 
tempt to  tell  any  man  how  to  vote.  The  Of- 
ficers of  the  Association  and  the  Editor  of  the 
Journal,  however,  feel  that  it  is  most  import- 
ant for  every  member  to  be  as  fully  informed 
as  possible  before  exercising  his  privilege  of 
voting.  With  this  thought  in  mind,  it  has 
been  decided  that  the  full  platform  of  both 
the  political  parties  will  be  reproduced  in  the 
Journal.  They  will  be  presented  in  order  of 
adoption  by  the  parties,  and  the  Democratic 
platform  will  be  found  on  page  151  of  this 
issue.  The  Republican  platform  in  its  entire- 
ty will  appear  in  the  October  issue. 

Let  it  be  emphasized  again  that  how  you 
vote  is  your  prerogative  and  comes  under  the 
heading  of  “jmur  business.”  However,  an  in- 
formed public  is  a prerequisite  to  good  gov- 
ernment under  the  American  system.  Read 
both  platforms  carefully ; make  your  decision 
by  the  philosophy  you  believe  in;  then  vote 
your  convictions  at  the  polls  in  November. 


SCHOOL  HEALTH  PROGRAM 

It  is  interesting  to  note  that  the  Committee 
on  School  Health  of  the  American  Academy 
of  Pediatrics  has  outlined  a health  program 
for  school  age  children  that  recommends  the 
employment  of  private  physicians  as  import- 
ant members  of  the  school  health  team. 

They  advocated  the  arrangement  to  be  on  a 
part-time  basis  to  bring  private  physicians 
into  the  program  and  further  to  encourage 
the  doctor’s  office  as  the  place  for  detailed 
examination  and  treatment. 

Such  immunization  procedures  as  are  indi- 
cated by  good  pediatric  practice  should,  in- 
sofar as  possible,  be  done  by  the  patient’s  pri- 
vate physician  or  local  health  department,  the 
Academy  committee  advised. 

Immunizations  against  diphtheria,  tetanus, 
pertussis,  poliomyelitis,  smallpox,  and  others, 
such  as  typhoid  which  may  be  indicated  by 
local  conditions,  are  generally  advised  by  the 
Committee  on  Control  of  Infectious  Diseases 
of  the  American  Academy  of  Pediatrics.  The 
doctors  said  that  the  schools  should  not  take 
responsibility  for  performing  the  actual  im- 
munizations. 

Describing  the  function  of  the  school  phy- 
sician, the  Academy  committee  said  that  he  is 
a health  adviser  instead  of  a source  of  medi- 
cal care.  He  is  a liaison  officer  between 
schools,  physicians,  and  health  agencies;  he 
advises  the  school  staff  on  medical  matters; 
he  analyzes,  with  the  nurse,  the  information 
she  has  gathered  about  pupils  and  their  fami- 
lies; and  he  advises  parents  and  children  as 


144 


J.  M.  A.  ALABAMA 


EDITORIAL  SECTION 


to  the  facilities  which  exist  for  solving  their 
medical  problems. 

He  should  not  replace  or  substitute  for  the 
child’s  own  physician  or  other  community 
health  service,  the  pediatricians  cautioned. 

The  school  health  team  should  strive  for 
the  cooperation  of  the  local  physicians.  In 
turn,  the  local  medical  societies  and  private 
physicians  should  cooperate  and  collaborate 
with  the  program,  the  committee  wrote. 

They  recommended  that  the  school  health 
team  employ  private  physicians  part  time 
and  give  pre-service  training  courses  for 
them  and  the  entire  staff.  The  team  should 
use  standard  forms  to  record  examinations 
and  progress  and  continuously  remind  local 
physicians  of  the  purpose  and  functions  of 
the  school  health  service.  They  should  make 
available  to  private  physicians  the  results  of 
any  examinations  and  appraisals  made  in  the 
school. 

The  committee  suggested  that  the  medical 
examination  be  used  as  an  opportunity  to 
promote  preventive  medicine,  health  im- 
provement, and  health  education,  rather  than 
solely  for  the  detection  of  health  impair- 
ments, and  suggested  a conference  should 
take  place  in  the  office  of  the  child’s  phy- 
sician. 

It  is  important  that  health  education  be  in- 
tegrated into  such  areas  as  language,  history, 
science,  physical  education,  and  social  studies, 
the  committee  held.  Such  integration  can- 
not be  accomplished  unless  the  teacher  has  a 
background  of  health  education  or  has  as- 
sistance from  the  group  cooperating  in  the 
school  health  program.  It  is  likewise  impoit- 
ant  that  courses  in  health  education  be  estab- 
lished. 

If  the  teaching  ability  of  the  professional 
educators  can  be  combined  with  the  medical 
knowledge  and  practical  experience  of  the 
practicing  physician  and  of  the  public  health 
physician,  children  will  be  better  instructed 
in  matters  of  health  and  disease,  the  pedia- 
tricians held. 


The  pediatricians  advocated  teamwork  by 
private  physicians,  school  physicians,  parents, 
teachers,  and  nurses  and  reported: 

The  major  purpose  of  a school  health  pro- 
gram is  to  maintain,  improve,  and  promote 
the  health  of  the  school  age  child.  The  pro- 
gram should  include  adequate  supervision  of 
the  physical,  mental,  emotional,  and  social 
aspects  of  school  life.  It  also  includes  plan- 
ning the  course  content  and  instruction  in  nu- 
trition and  health  education,  including  acci- 
dent prevention,  recreation,  and  physical 
education. 

To  carry  out  these  objectives,  the  pediatri- 
cians said  three  services  are  needed: 

1.  Health  Appraisal.  Routine,  regular 
physical  examinatons,  preferably  prior  to  en- 
trance to  school,  during  the  intermediate 
grades,  at  entrance  to  secondary  school,  and 
before  completion  of  secondary  school. 

2.  Follow-up.  It  is  a waste  of  time  and  ef- 
fort to  find  the  child  with  a health  problem 
unless  something  is  done  about  it.  Some- 
thing must  be  done  to  insure  that  the  child  is 
placed  under  adequate  medical  supervision 
for  the  correction  of  any  remediable  abnor- 
mality found  at  the  time  of  the  examination 
or  to  obtain  medical  advice  as  to  his  adjust- 
ment to  education  in  cases  where  the  defect 
cannot  be  remedied. 

3.  Parent  Education  and  Parent  Counsel- 
ing. An  important  function  of  the  school 
health  program  is  to  educate  and  counsel  the 
parents  in  discharging  the  responsibility  that 
the  child’s  health  rests  with  his  parents.  It 
is  important  to  get  the  co-operation  of  the 
parents  and  to  motivate  them  to  heed  their 
physician’s  advice  in  obtaining  the  necessary 
medical  care. 

The  pediatricians  outlined  details  of  the 
parts  each  member  of  the  team  plays.  Par- 
ents should  be  alert  to  notice  changes  in  their 
children’s  appearance  or  actions  which  sug- 
gest need  for  medical  advice,  they  counseled. 

Teachers  may  be  prepared  through  their  in- 
terests and  education  to  observe  pupils  for 


SEPTEMBER  I960— VOL.  30,  NO.  3 


145 


EDITORIAL  SECTION 


deviations  from  normal  appearance  and  be- 
havior. 

Not  all  teachers  are  adequately  prepared 
or  equipped  to  assume  this  responsibility,  the 
report  said.  Some  teachers  are  not  good  ob- 
servers. Their  many  pedagogic  duties  are 
naturally  their  major  interest.  In-service 
training  for  their  part  in  the  school  health 
program  is  essential. 

The  committee  recommended  that  the 
teacher  transmit  her  impressions  to  the  phy- 
sician or  school  nurse  and  to  the  parents  only 
if  there  is  no  intermediate  medical  personnel 
in  the  school.  If  she  consults  directly  with 
the  parent,  she  should  be  very  careful  not  to 
make  a diagnosis,  which,  if  wrong,  could  be 
damaging  to  both  the  parents  and  child.  In- 
stead, she  should  point  out  apparent  func- 
tional deviations  and  recommend  medical  at- 
tention. Her  exact  procedure  will  depend  on 
the  individual  case  but  will  always  call  for 
tact  and  discrimination. 

The  committee  praises  the  importance  of 
the  teacher  and  that  of  the  school  nurse.  The 
nurse  is  at  the  center  of  activities  and  has  di- 
rect relationships  with  teachers,  physicians, 
health  officials,  and  parents.  The  nurse  helps 
train  teachers  in  observation  and  screening. 
She  assists  the  school  physician,  prepares  rec- 
ords and  medical  histories,  and  is  a counsel- 
lor and  friend  to  the  parent.  Her  position  in 
relation  to  the  community  was  emphasized: 

She  relates  the  health  services  in  schools  to 
the  work  of  other  community  health  services, 
and  many  times  she  is  the  interpreter  or  co- 
ordinator of  health  activities  within  the 
school.  She  has  an  important  role  in  inter- 
preting handicapped  children  to  the  school 
staff;  and  she  works  with  guidance,  psycho- 
logic and  special  education  services  on  their 
behalf. 

Much  of  her  work  can  be  accomplished 
through  the  school  health  council;  on  it  the 
nurse  is  usually  the  motivating  and  coordi- 
nating force. 

HEALTH  INSURANCE  ON  CREDIT 
CARD  PROPOSED 

The  rapidly  burgeoning  U.  S.  credit  cai'd 
craze  will  be  extended  to  the  field  of  health 


insurance  if  a San  Francisco  insurance  execu- 
tive has  his  way. 

During  the  annual  convention  of  the  Na- 
tional Association  of  Insurance  Commission- 
ers in  San  Francisco  recently,  Michael  C. 
Fields,  president  of  United  States  Underwrit- 
ing Company,  proposed  what  he  calls  Medi- 
card — for  catastrophic-illness  coverage  at  all 
age  levels. 

The  Medicard  plan’s  main  points: 

For  a set  premium,  not  yet  worked  out, 
each  subscriber  would  have  complete  cov- 
erage for  all  illness  costing  from  $1,000  to 
$10,000.  He  would  have  to  pay  the  first  $1,- 
000  himself,  but — thanks  to  the  plan’s  credit 
feature — payments  could  be  spread  over  five 
years. 

Though  Mr.  Fields  has  registered  his  Medi- 
card plan  with  the  California  State  Insurance 
Department,  he  said  he  does  not  intend  to  in- 
corporate or  otherwise  protect  the  idea. 

PHYSICALS  REQUIRED 
FOR  DRIVER'S  LICENSE 

A physical  examination  by  a physician  is 
now  required  of  all  new  applicants  for  a driv- 
er’s license  in  Pennsylvania. 

This  is  the  first  step  under  a new  program 
requiring  all  drivers  in  the  state  to  have  pe- 
riodic physical  check-ups.  It  is  estimated 
that  by  1962  the  plan  will  be  in  full  swing, 
calling  for  examinations  every  ten  years  for 
persons  up  to  60  and  every  five  years  there- 
after. 

All  physicians  in  the  state  have  been  ad- 
vised of  the  program,  developed  by  the  State 
Secretary  of  Health,  Dr.  Charles  L.  Wilbar, 
Jr.,  and  a Pennsylvania  Medical  Society  ad- 
visory committee.  It  is  expected  that  the  ma- 
jority of  examinations  will  be  made  by  fami- 
ly doctors;  no  fee  has  yet  been  set. 

Among  the  grounds  listed  for  refusing  a 
driver’s  license  are:  fixed  hypertension  of 
180/100  or  above,  plus  complications;  neuro- 
psychiatric disorders  which  may  prevent  rea- 
sonable control  of  a motor  vehicle;  conditions 
causing  repeated  lapses  of  consciousness, 
such  as  epilepsy,  narcolepsy  and  hysteria, 
within  the  past  two  years;  uncontrolled  brit- 
tle diabetes;  chronic  alcoholism;  and  narcotics 
addiction. 


146 


J.  M.  A.  ALABAMA 


FALL  OUTS 


Do  you  have  a fall  out  shelter  on  your 
premises?  Would  you  think  that  all  our  citi- 
zens should  have  one  available?  Would  you 
recommend  that  the  medical  profession  take 
the  lead  in  urging  that  every  one  have  one? 

Our  Disaster  Committee  and  Dr.  David  Mc- 
Coy, Director  of  Disaster  Services,  are  busy 
with  plans  to  organize  the  profession  and  its 
necessary  adjuncts  in  the  various  cities  of  the 
state  into  working  units  for  the  care  of  nu- 
clear war  victims  and  for  the  care  of  those 
suffering  from  other  mass-type  injuries. 

Since,  by  prevailing  winds,  radioactive  ma- 
terials may  be  carried  miles  from  the  bomb- 
ing site,  should  not  all  citizens  have  protec- 
tive shelters  available  with  food,  water,  light, 
radio,  et  cetera  needed  for  at  least  two  weeks? 
I think  they  should.  Education  is  our  respon- 
sibility. 

The  other  “fall  out”  I want  to  mention  is 
concerned  with  socialized  medicine. 

Due  to  political  expediency,  the  Democrats 
and  Republicans  are  using  the  aged  problem 
to  get  votes.  Another  give  away!  Another 


bureaucracy  to  be  established  in  Washington! 
Another  liberty  to  be  taken  from  our  citizens 
— the  free  choice  of  physicians  and  hospitals. 
Look  at  Saskatchewan! 

Our  Committee  on  Legislation,  led  by  Dr. 
Vaun  Adams,  has  been  doing  a fine  job  on 
this  problem  for  the  last  several  years. 

At  the  moment,  it  looks  as  if  our  opponents 
may  have  their  foot  in  the  door. 

We  must  build  shelters  for  our  citizens,  and 
we  must  build  shelters  for  our  present  way  of 
life  constantly  by  reminding  our  political  rep- 
resentatives in  Washington  what  so  many  of 
these  socialistic  schemes  will  actually  lead  to. 
These  shelters  must  be  built  to  protect  all  of 
us  now  and  in  the  future. 


SEPTEMBER  I960— VOL.  30,  NO.  3 


147 


NEW  MEMBERS— of  the  Committee  on  Public 
Relations  are  shown  outside  of  the  Association 
Home  with  Chairman  J.  Michaelson  (center).  They 
are  (bottom  to  top)  Dr.  William  L.  Smith,  secre- 
tary-treasurer, ex-officio  member;  Mrs.  John  T. 
Morris,  president  of  the  Women’s  Auxiliary,  ex- 
officio  member;  Dr.  John  W.  Simpson,  president- 
elect, ex-officio  member;  and  Dr.  Norman  C. 
Veale,  newly  appointed  member. 


PUBLIC  RELATIONS  COMMITTEE 

Dr.  Luther  Hill  of  Montgomery  was  ap- 
pointeci  vice-chairman  of  the  Association’s 
Public  Relations  Committee  at  a meeting  of 
the  committee  on  July  31. 

Meeting  in  the  Association’s  Conference 
Room  with  Chairman  J.  Michaelson  were  D. 
G.  Gill,  C.  A.  Grote,  Jr.,  L.  L.  Hill,  R.  O.  Rut- 
land, Jr.,  John  W.  Simpson,  H.  M.  Simpson, 
W.  L.  Smith,  Norman  Veale,  and  Mrs.  John 
T.  Morris. 

In  reporting  on  the  progress  of  the  “Careers 
in  Medicine”  brochure.  Dr.  Rutland  pointed 


out  that  there  is  a great  need  for  such  a fold- 
er because  the  physician  population  in  Ala- 
bama is  much  lower  than  the  national  average 
and  because  the  Medical  College  of  Alabama 
is  presently  receiving  from  one  and  a half  to 
two  applications  for  each  vacancy  in  the 
freshman  class.  Dr.  Rutland  said  he  felt  it 
was  the  duty  of  the  profession  to  stimulate 
high  school  students  to  study  medicine.  He 
stated  that  the  physicians  of  the  state  are  not 
aware  of  the  physician  shortage,  and  he  sug- 
gested that  they  be  notified  via  county  medi- 
cal societies. 

A sample  layout  of  the  proposed  brochure 
was  shown  to  committee  members.  Dr.  John 
W.  Simpson  suggested  that  the  brochure 
should  include  the  fact  that  during  residency 
a student  can  now  be  sufficiently  supported 
by  part-time  employment,  loans,  and  grants. 

Dr.  Gill  pointed  out  that,  by  virtue  of  the 
state  medical  scholarship  program  as  ap- 
proved by  the  Legislature,  grants  can  now  be 
given  at  any  stage  in  the  medical  student’s 
training,  not  necessarily  as  a freshman.  He 
explained  that  last  year  the  grants  were  dis- 
tributed at  all  levels. 

The  committee  approved  the  copy  and  lay- 
out for  the  brochure,  and  it  will  be  printed 
and  available  by  October  1. 

Dr.  Rutland  reported  to  the  committee  on 
the  Third  Annual  Athletic  Injuries  Confer- 
ence held  on  August  10  at  the  University  of 
Alabama.  He  pointed  out  that  there  has  been 
a number  of  complications  in  arranging  the 
program  this  year.  The  coaches,  he  said,  are 
very  interested  in  the  program;  but  the  Uni- 
versity officials  are  unenthusiastic  over  the 
conference.  The  committee  suggested  that 
Drs.  Michaelson  and  Rutland  arrange  a meet- 
ing with  Coach  Bryant  and  Mr.  Cliff  Harper, 
executive  secretary  of  the  Alabama  High 


148 


J.  M.  A.  ALABAMA 


ORGANIZATION  SECTION 


School  Coaches  Association,  to  foster  better 
relations  in  the  future;  and  if  they  are  not  re- 
ceptive to  the  idea,  then  consider  the  possi- 
bilities of  the  Association’s  sponsoring  its  own 
conference  at  another  time  and  place. 

Mrs.  John  T.  Morris,  president  of  the  Wom- 
an’s Auxiliary,  gave  a report  on  the  1961  Es- 
say Contest.  A list  of  rules  and  regulations 
governing  the  forthcoming  contest  was  read 
and  approved  by  the  committee. 

In  reporting  on  the  welfare  survey  con- 
ducted by  the  committee  in  every  county.  Dr. 
Michaelson  stated  that  the  survey  showed 
that  none  of  the  County  Welfare  Boards  had 
any  grievances  with  any  County  Medical  So- 
cieties. Dr.  John  W.  Simpson  stated  that  this 
information  should  be  included  in  the  com- 
mittee’s annual  report. 

Dr.  Michaelson  reported  that  a Physician- 
Pharmacist  Code  of  Understanding  had  been 
prepared  by  a medical  sub-committee  and  a 
sub-committee  of  the  Pharmaceutical  Asso- 
ciation. The  code,  rules  of  conduct  for  the 
members  of  both  groups,  was  approved  by  the 
Medical  Association  in  Mobile  in  April.  Up- 
on a resolution  by  Dr.  Veale  the  committee 
voted  to  share  with  the  pharmacists  the  cost 
of  printing  and  mailing  the  code  to  members 
of  the  Medical  Association  of  the  State  of 
Alabama. 

A progress  report  on  the  orientation  pro- 
gram for  new  members  was  given  by  Dr.  Hill. 
As  of  January  1,  1960,  all  new  members  of  the 
Association  will  be  required  to  take  the  orien- 
tation program  which  will  include  the  follow- 
ing topics:  “Alabama  Medical  Organization”; 
“The  Board  of  Censors — Their  Duties  and  Re- 
sponsibilities”; “State  Health  Officer — His 
Duties  and  Responsibilities”;  “Services  Ren- 
dered by  State  and  County  Health  Depart- 
ments”; “Tuberculosis,  Cancer,  Mental  Health 
and  Venereal  Disease  Programs  of  the  State”; 
“Active  Committees  of  the  State  Medical  As- 
sociation”; “Your  Association  Home”;  “Dis- 
bursement of  Annual  Dues”;  “Medical  Ethics 
and  Medical  Etiquette”;  “Medical  Malprac- 
tice”; “Blue  Cross-Blue  Shield”;  “The  Phy- 
sician and  Law  Enforcement”;  and  “Medical 
Economics”. 


Chairman  Michaelson  announced  that  a 
County  Medical  Society  Officers  Conference 
will  be  held  in  Montgomery  on  September  25. 
The  conference  is  to  acquaint  County  Medical 
Society  officers  with  programs  of  the  Associa- 
tion that  require  the  cooperation  of  county 
societies. 


MEDICAL  ASSISTANTS  COURSE 


MEDICAL  ASSISTANTS— from  throughout  Ala- 
bama met  with  Dr.  Harry  M.  Simpson,  Jr.,  member 
of  the  Committee  on  Public  Relations  ( left  stand- 
ing) and  Mr.  Gordon  E.  P.  Wright,  director  of  com- 
merce of  the  University  of  Alabama  Extension 
Services,  on  July  30  in  Montgomery  for  the  pur- 
pose of  mapping  out  plans  for  their  fourth  course. 


The  sub-committee  on  medical  assistants 
courses  met  at  the  Association  Building  in 
Montgomery  on  July  30  for  the  purpose  of 
determining  whether  or  not  to  continue  the 
courses. 

Meeting  with  Mr.  Gordon  E.  P.  Wright,  di- 
rector of  commerce  of  the  University  of  Ala- 
bama Extension  Services,  were  Medical  As- 
sistants Rhoda  P.  Cummings,  Helen  Bain- 
bridge,  Catherine  Calafrancisco  of  Birming- 
ham; Myrtice  Seale,  Victoria  Ratley,  Sara 
Price,  Elizabeth  Cox,  Barbara  Jolley,  Lennis 
Shelton  of  Montgomery;  Iris  Holley,  Dorothy 
Grosse,  Marie  Swindle,  Norma  Kirk  of  Tus- 
caloosa; Esther  Loyd,  Theodore;  Gloria 
Stroecker,  Mobile;  Frances  Spates,  Vincent; 
Ruth  Reynolds,  Gadsden.  Representing  the 
Medical  Association  were  Dr.  Harry  M.  Simp- 


SEPTEMBER  I960— VOL.  30,  NO.  3 


149 


ORGANIZATION  SECTION 


son,  Jr.,  Florence,  and  Executive  Assistant 
W.  V.  Wallace. 

Mr.  Wright  outlined  to  the  group  the 
progress  of  the  three  medical  assistants 
courses  and  asked  the  group  if  they  wished  to 
continue  the  series. 

The  medical  assistants  were  very  enthusias- 
tic about  continuing  the  courses  and  made 
suggestions  regarding  future  courses. 

The  secretaries  suggested  that  course  four 
should  be  on  one  of  the  following  subjects: 
clinical  technology,  medical  terminology, 
anatomy,  collection  methods  and  procedures, 
legal  situations  and  procedures,  insurance 
and  public  relations. 

They  also  stated  that  they  would  like  to  re- 
ceive credit  of  some  description  for  all  courses 
in  the  future. 

Everyone  present  thought  that  an  examina- 
tion should  be  given  on  each  course  in  order 
to  obtain  certification.  Thus  the  certificate 
could  read  “completed”  rather  than  attended. 

The  University  of  Alabama  should  stage  the 
examinations  and  grant  the  certificates,  ac- 
cording to  the  medical  assistants. 

The  group  expressed  a desire  to  start  train- 
ing for  a national  certification  of  some  de- 
scription. This,  they  explained,  could  be  set 
up  by  their  own  national  organization. 

Mr.  Wright  told  the  group  that  proposed 
course  four  would  probably  be  ten  sessions, 
two  hours  each  session;  and  the  fee  would  be 
approximately  $15.00.  The  course,  he  said, 
would  incorporate  visual  aids  and  could  be 
offered  by  University  Extension  Centers 
throughout  the  state. 

Dr.  Simpson  stated  that  he  could  not  see 
how  courses  of  a technical  nature  which  the 
girls  suggested  could  be  of  great  benefit  to 
them.  He  further  stated  he  was  expressing 
his  own  personal  opinion  and  not  that  of  the 
Medical  Association. 

There  being  no  further  business,  the  meet- 
ing was  adjourned. 

150 


FEDERAL  COMPETITION? 

The  medical  profession  has  frequently 
pointed  out  that  expanding  government  med- 
ical care  programs  make  staffing  of  commu- 
nity hospitals,  which  serve  all  the  people, 
more  difficult — since  the  governmental  pro- 
gram, tax-financed,  does  not  have  to  pay  sala- 
ries out  of  earned  income.  A 1958  report  of 
the  Women’s  Bureau  of  the  Department  of 
Labor  on  the  average  weekly  earnings  of  gen- 
eral duty  nurses  in  16  areas  throughout  the 
country  showed  that  governmental  hospital 
pay  was  consistently  higher — from  $2.50  to 
$18.00  higher  than  in  private  hospitals  in  the 
same  area. 

A new  Department  of  Labor  report,  the 
“1959  Occupational  Outlook  Handbook,”  re- 
inforces these  data.  Using  1957  and  1958  fig- 
ures, it  shows  the  average  starting  salary  for 
baccalaureate  degree  nurses  as  $3,739  per 
year,  but  the  minimum  Federal  starting  sala- 
ry as  $4,040. 

Annual  salaries  of  office  nurses  averaged 
$3,600;  public  health  nurses  with  private 
agencies,  $3,881;  private  duty  nurses,  $4,160; 
local  government  public  health  nurses,  $4,301; 
and  board  of  education  staff  nurses,  $4,854. 
Half  of  the  federally  employed  nurses  were 
earning  between  $4,490  and  $5,390. 

In  the  field  of  medical  education,  the  Civil 
Service  Commission  set  new  maximum  sti- 
pends for  medical  and  dental  interns  and  resi- 
dents under  Federal  Civil  Service  in  October 
1959.  For  the  purpose  of  comparison  with  lo- 
cal stipends,  the  new  federal  maximums  are: 
approved  internships,  $3,800  per  year;  first 
year  approved  residency,  $4,400;  second  year, 
$4,800;  third  year,  $5,200;  fourth  year,  $5,700. 


J.  M.  A.  ALABAMA 


THE  DEMOCRATIC  PLATEORM 

The  Rights  Of  Man 

Report  of  the  Committee  on 
Resolutions  ami  Platform 
as  Adopted  at  the 
Democratic  National  Convention, 

Los  Angeles,  July  12,  1960. 


I 

In  1796,  in  America's  first  contested  nation- 
al election,  our  Party,  under  the  leadership 
of  Thomas  Jefferson,  campaigned  on  the  prin- 
ciples of  "The  Rights  of  Man." 

Ever  since,  these  four  words  have  under- 
scored our  identity  with  the  plain  p>eople  of 
America  and  the  world. 

In  periods  of  national  crisis,  we  Democrats 
have  returned  to  these  words  for  renewed 
strength.  We  return  to  them  today. 

In  1960,  "The  Rights  of  Man"  are  still  the 
issue. 

It  is  our  continuing  responsibility  to  pro- 
vide an  effective  instrument  of  political  ac- 
tion for  every  American  who  seeks  to 
strengthen  these  rights — everywhere  here  in 
America,  and  everywhere  in  our  20th  Cen- 
tury world. 


II 

The  common  danger  of  mankind  is  war  and 
the  threat  of  war.  Today,  three  billion  hu- 
man beings  live  in  fear  that  some  rash  act  or 
blunder  may  plunge  us  all  into  a nuclear  hol- 
ocaust which  will  leave  only  ruined  cities, 
blasted  homes,  and  a poisoned  earth  and  sky. 

Our  objective,  however,  is  not  the  right  to 
co-exist  in  armed  camps  on  the  same  planet 
with  totalitarian  ideologies;  it  is  the  creation 
of  an  enduring  peace  in  which  the  universal 
values  of  human  dignity,  truth,  and  justice 
under  law  are  finally  secured  for  all  men 
everywhere  on  earth. 

If  America  is  to  work  effectively  for  such  a 
peace,  we  must  first  restore  our  national 
strength — military,  political,  economic,  and 
moral. 


SEPTEMBER  I960— VOL.  30,  NO.  3 


151 


THE  ASSOCIATION  FORUM 


National  Defense 

The  new  Democratic  administration  will 
recast  our  military  capacity  in  order  to  pro- 
vide forces  and  weapons  of  a diversity,  bal- 
ance, and  mobility  sufficient  in  quantity  and 
quality  to  deter  both  limited  and  general  ag- 
gressions. 

When  the  Democratic  administration  left 
office  in  1953,  the  United  States  was  the  pre- 
eminent power  in  the  world.  Most  free  na- 
tions had  confidence  in  our  will  and  our  abili- 
ty to  carry  out  our  commitments  to  the  com- 
mon defense. 

Even  those  who  wished  us  ill  respected  our 
power  and  influence. 

The  Republican  administration  has  lost  that 
position  of  pre-eminence.  Over  the  past  7V2 
years,  our  military  power  has  steadily  de- 
clined relative  to  that  of  the  Russians  and  the 
Chinese  and  their  satellites. 

This  is  not  a partisan  election-year  charge. 
It  has  been  persistently  made  by  high  officials 
of  the  Republican  administration  itself.  Be- 
fore Congressional  committees  they  have  tes- 
tified that  the  Communists  will  have  a dan- 
gerous lead  in  intercontinental  missiles 
through  1963 — and  that  the  Republican  ad- 
ministration has  no  plans  to  catch  up. 

They  have  admitted  that  the  Soviet  Union 
leads  in  the  space  race — and  that  they  have 
no  plans  to  catch  up. 

They  have  also  admitted  that  our  conven- 
tional military  forces,  on  which  we  depend 
for  defense  in  any  non-nuclear  war,  have  been 
dangerously  slashed  for  reasons  of  “economy” 
— and  that  they  have  no  plans  to  reverse  this 
trend. 

As  a result,  our  military  position  today  is 
measured  in  terms  of  gaps — missile  gap,  space 
gap,  limited  war  gap. 

To  recover  from  the  errors  of  the  past  seven 
years  will  not  be  easy. 

This  is  the  strength  that  must  be  erected; 

1.  Deterrent  military  power  such  that  the 
Soviet  and  Chinese  leaders  will  have  no 
doubt  that  an  attack  on  the  United  States 


would  surely  be  followed  by  their  own  de- 
struction. 

2.  Balanced  conventional  military  forces 
which  will  permit  a response  graded  to  the 
intensity  of  any  threats  of  aggressive  force. 

3.  Continuous  modernization  of  these 
foi'ces  through  intensified  research  and  de- 
velopment, including  essential  programs  now 
slowed  down,  terminated,  suspended,  or  neg- 
lected for  lack  of  budgetary  support. 

A first  order  of  business  of  a Democratic 
administration  will  be  a complete  re-exami- 
nation of  the  organization  of  our  armed 
forces. 

A military  organization  structure,  conceiv- 
ed before  the  revolution  in  weapon  tech- 
nology, cannot  be  suitable  for  the  strategic 
deterrent,  continental  defense,  limited  war, 
and  military  alliance  requirements  of  the 
1960’s. 

We  believe  that  our  armed  forces  should  be 
organized  more  nearly  on  the  basis  of  func- 
tion, not  only  to  produce  greater  military 
strength,  but  also  to  eliminate  duplication  and 
save  substantial  sums. 

We  pledge  our  will,  energies,  and  resources 
to  oppose  Communist  aggression. 

Since  World  War  II,  it  has  been  clear  that 
our  own  security  must  be  pursued  in  concert 
with  that  of  many  other  nations. 

The  Democratic  administrations  which,  in 
World  War  II,  led  in  forging  a mighty  and 
victorious  alliance,  after  the  war  took  the  ini- 
tiative in  creating  the  North  Atlantic  Treaty 
Organization,  the  greatest  peace-time  alliance 
in  history. 

This  alliance  has  made  it  possible  to  keep 
Western  Europe  and  the  Atlantic  Community 
secure  against  Communist  pressures. 

Our  present  system  of  alliances  was  begun 
in  a time  of  an  earlier  weapons  technology 
when  our  ability  to  retaliate  against  Commu- 
nist attack  required  bases  all  around  the  pe- 
riphery of  the  Soviet  Union.  Today,  because 
of  our  continuing  weakness  in  mobile  weap- 
ons systems  and  intercontinental  missiles,  our 


152 


J.  M.  A.  ALABAMA 


THE  ASSOCIATION  FORUM 


defenses  still  depend  in  part  on  bases  beyond 
our  borders  for  planes  and  shorter  range 
missiles. 

If  an  alliance  is  to  be  maintained  in  vigor, 
its  unity  must  be  reflected  in  shared  purposes. 
Some  of  our  allies  have  contributed  neither 
devotion  to  the  cause  of  freedom  nor  any  real 
military  strength. 

The  new  Democratic  administration  will 
review  our  system  of  pacts  and  alliances.  We 
shall  continue  to  adhere  to  our  treaty  obliga- 
tions, including  the  commitment  of  the  UN 
charter  to  resist  aggression.  But  we  shall  also 
seek  to  shift  the  emphasis  of  our  cooperation 
from  military  aid  to  economic  development, 
wherever  this  is  possible. 

Civil  Defense.  We  commend  the  work  of 
the  civil  defense  groups  throughout  the  na- 
tion. A strong  and  effective  civil  defense  is 
an  essential  element  in  our  nation’s  defense. 

The  new  Democratic  administration  will 
undertake  a full  review  and  analysis  of  the 
programs  that  should  be  adopted  if  the  pro- 
tection possible  is  to  be  provided  to  the 
civilian  population  of  our  nation. 


Arms  Control 

A fragile  power  balance  sustained  by  mu- 
tual nuclear  terror  does  not,  however,  consti- 
tute peace.  We  must  regain  the  initiative  on 
the  entire  international  front  with  effective 
new  policies,  to  create  the  conditions  for 
peace. 

There  are  no  simple  solutions  to  the  in- 
finitely complex  challenges  which  face  us. 
Mankind's  eternal  dream,  a world  of  peace, 
can  only  be  built  slowly  and  patiently. 

A primary  task  is  to  develop  responsible 
proposals  that  will  help  break  the  deadlock 
on  arms  control. 

Such  proposals  should  include  means  for 
ending  nuclear  tests  under  workable  safe- 
guards, cutting  back  nuclear  weapons,  reduc- 
ing conventional  forces,  preserving  outer 
space  for  peaceful  purposes,  preventing  sur- 


prise attack,  and  limiting  the  risk  of  accident- 
al war. 

This  requires  a national  peace  agency  for 
disarmament  planning  and  research  to  mus- 
ter the  scientific  ingenuity,  coordination,  con- 
tinuity, and  seriousness  of  purpose  which  are 
now  lacking  in  our  arms  control  efforts. 

The  national  peace  agency  would  develop 
the  technical  and  scientific  data  necessary  for 
serious  disarmament  negotiations,  would  con- 
duct research  in  cooperation  with  the  Defense 
Department  and  Atomic  Energy  Commission 
on  methods  of  inspection  and  monitoring 
arms  control  agreements,  particularly  agree- 
ments to  control  nuclear  testing,  and  would 
provide  continuous  technical  advice  to  our 
disarmament  negotiators. 

As  with  armaments,  so  with  disarmament, 
the  Republican  administration  has  provided 
us  with  much  talk  but  little  constructive  ac- 
tion. Representatives  of  the  United  States 
have  gone  to  conferences  without  plans  or 
preparation.  The  administration  has  played 
opportunistic  politics,  both  at  home  and 
abroad. 

Even  during  the  recent  important  negotia- 
tions at  Geneva  and  Paris,  only  a handful  of 
people  were  devoting  full  time  to  work  on 
the  highly  complex  problem  of  disarmament. 

More  than  $100  billion  of  the  world’s  pro- 
duction now  goes  each  year  into  armaments. 
To  the  extent  that  we  can  secure  the  adoption 
of  effective  arms  control  agreements,  vast  re- 
sources will  be  freed  for  peaceful  use. 

The  new  Democratic  administration  will 
plan  for  an  orderly  shift  of  our  expenditures. 
Long-delayed  reductions  in  excise,  corpora- 
tion, and  individual  income  taxes  will  then  be 
possible.  We  can  also  step  up  the  pace  in 
meeting  our  backlog  of  public  needs  and  in. 
pursuing  the  promise  of  atomic  and  space 
science  in  a peaceful  age. 

As  world-wide  disarmament  proceeds,  it 
will  free  vast  resources  for  a new  internation- 
al attack  on  the  problem  of  world  poverty. 


SEPTEMBER  I960— VOL.  30,  NO.  3 


153 


THE  ASSOCIATION  FORUM 


The  Instruments  of  Foreign  Policy 

American  foreign  policy  in  all  its  aspects 
must  be  attuned  to  our  world  of  change. 

We  will  recruit  officials  whose  experience, 
humanity,  and  dedication  fit  them  for  the 
task  of  effectively  representing  America 
abroad. 

We  will  provide  a more  sensitive  and  crea- 
tive direction  to  our  overseas  information 
program.  And  we  will  overhaul  our  adminis- 
trative machinery  so  that  America  may  avoid 
diplomatic  embarrassments  and  at  long  last 
speak  with  a single  confident  voice  in  world 
affairs. 

The  "image"  of  America.  First,  those  men 
and  women  selected  to  represent  us  abroad 
must  be  chosen  for  their  sensitive  under- 
standing of  the  peoples  with  whom  they  will 
live.  We  can  no  longer  afford  representa- 
tives who  are  ignorant  of  the  language  and 
culture  and  politics  of  the  nation  in  which 
they  represent  us. 

Our  information  programs  must  be  more 
than  news  broadcasts  and  boastful  recitals  of 
our  accomplishments  and  our  material  riches. 
We  must  find  ways  to  show  the  people  of  the 
world  that  we  share  the  same  goals — dignity, 
health,  freedom,  schools  for  children,  a place 
in  the  sun — and  that  we  will  work  together  to 
achieve  them. 

Our  program  of  visits  between  Americans 
and  people  of  other  nations  will  be  expanded, 
with  special  emphasis  upon  students  and 
younger  leaders.  We  will  encourage  study  of 
foreign  languages.  We  favor  continued  sup- 
port and  extension  of  such  progams  as  the 
East-West  cultural  center  established  at  the 
University  of  Hawaii.  We  shall  study  a simi- 
lar center  for  Latin  America,  with  due  con- 
sideration of  the  existing  facilities  now  avail- 
able in  the  Canal  Zone. 

National  Policy  Machinery.  In  the  present 
administration,  the  National  Security  Coun- 
cil has  been  used  not  to  focus  issues  for  de- 
cision by  the  responsible  leaders  of  govern- 
ment, but  to  paper  over  problems  of  policy 
with  “agreed  solutions”  which  avoid  de- 
cisions. 


The  mis-handling  of  the  U-2  espionage 
flights — the  sorry  spectacle  of  official  denial, 
retraction,  and  contradiction — and  the  ad- 
mitted mis-judging  of  Japanese  public  opin- 
ion are  only  two  recent  examples  of  the  break- 
down of  the  Administration’s  machinery  for 
assembling  facts,  making  decisions,  and  co- 
ordinating action. 

The  Democratic  Party  welcomes  the  study 
now  being  made  by  the  Senate  Subcommittee 
on  National  Policy  Machinery.  The  new  Dem- 
ocratic administration  will  revamp  and  sim- 
plify this  cumbersome  machinery. 

World  Trade 

World  trade  is  more  than  ever  essential  to 
world  peace.  In  the  tradition  of  Cordell  Hull, 
we  shall  expand  world  trade  in  every  respon- 
sible way. 

Since  all  Americans  share  the  benefits  of 
this  policy,  its  costs  should  not  be  the  burden 
of  a few.  We  shall  support  practical  meas- 
ures to  ease  the  necessary  adjustments  of  in- 
dustries and  communities  which  may  be  un- 
avoidably hurt  by  increases  in  imports. 

World  trade  raises  living  standards,  widens 
markets,  reduces  costs,  increases  profits,  and 
builds  political  stability  and  international 
economic  cooperation. 

However,  the  increase  in  foreign  imports 
involves  costly  adjustment  and  damage  to 
some  domestic  industries  and  communities. 
The  burden  has  been  heavier  recently  because 
of  the  Republican  failure  to  maintain  an  ade- 
quate rate  of  economic  growth,  and  the  re- 
fusal to  use  public  programs  to  ease  necessary 
adjustments. 

The  Democratic  administration  will  help 
trade-affected  industries  by  measures  consis- 
tent with  economic  growth,  orderly  transi- 
tion, fair  competition,  and  the  long-run  eco- 
nomic strength  of  all  parts  of  our  nation. 

Trade-affected  industries  and  communities 
need  and  deserve  appropriate  help  through 
trade  adjustment  measures  such  as  direct 
loans,  tax  incentives,  defense  contracts  pri- 
ority, and  retraining  assistance. 


154 


J.  M.  A.  ALABAMA 


THE  ASSOCIATION  FORUM 


Our  government  should  press  for  reduction 
of  foreign  barriers  to  the  sale  of  the  products 
of  American  industry  and  agriculture.  These 
are  particularly  severe  in  the  case  of  fruit 
products.  The  present  balance  of  payments 
situation  provides  a favorable  opportunity  for 
such  action. 

The  new  Democratic  administration  will 
seek  international  agreements  to  assure  fair 
competition  and  fair  labor  standards  to  pro- 
tect our  own  workers  and  to  improve  the  lot 
of  workers  elsewhere. 

Our  domestic  economic  policies  and  our  es- 
sential foreign  policies  must  be  harmonious. 

To  sell,  we  must  buy.  We  therefore  must 
resist  the  temptation  to  accept  remedies  that 
deny  American  producers  and  consumers  ac- 
cess to  world  markets  and  destroy  the  pros- 
perity of  our  friends  in  the  non-Communist 
world. 

Immigration 

We  shall  adjust  our  immigration,  nationali- 
ty and  refugee  policies  to  eliminate  discrimi- 
nation and  to  enable  members  of  scattered 
families  abroad  to  be  united  with  relatives 
already  in  our  midst. 

The  national  origins  quota  system  of  limit- 
ing immigration  contradicts  the  founding 
principles  of  this  nation.  It  is  inconsistent 
with  our  belief  in  the  rights  of  man.  This 
system  was  instituted  after  World  War  I as 
a policy  of  deliberate  discrimination  by  a Re- 
publican administration  and  Congress. 

The  revision  of  immigration  and  national- 
ity laws  we  seek  will  implement  our  belief 
that  enlightened  immigration,  naturalization 
and  refugee  policies  and  humane  administra- 
tion of  them  are  important  aspects  of  our 
foreign  policy. 

These  laws  will  bring  greater  skills  to  our 
land,  reunite  families,  permit  the  United 
States  to  meet  its  fair  share  of  world  pro- 
grams of  rescue  and  rehabilitation,  and  take 
advantage  of  immigration  as  an  important 
factor  in  the  growth  of  the  American  econ- 
omy. 


In  this  World  Refugee  Year  it  is  our  hope 
to  achieve  admission  of  our  fair  share  of  ref- 
ugees. We  will  institute  policies  to  alleviate 
suffering  among  the  homeless  wherever  we 
are  able  to  extend  our  aid. 

We  must  remove  the  distinctions  between 
native-born  and  naturalized  citizens  to  ensure 
full  protection  of  our  laws  to  all.  There  is  no 
place  in  the  United  States  for  “second-class 
citizenship.” 

The  protections  provided  by  due  process, 
right  of  appeal,  and  statutes  of  limitation,  can 
be  extended  to  non-citizens  without  hamper- 
ing the  security  of  our  nation. 

We  commend  the  Democratic  Congress  for 
the  initial  steps  that  have  recently  been  taken 
toward  liberalizing  changes  in  immigration 
law.  However,  this  should  not  be  a piece- 
meal project  and  we  are  confident  that  a 
Democratic  President  in  cooperation  with 
Democratic  Congresses  will  again  implant  a 
humanitarian  and  liberal  spirit  in  our  nation’s 
immigration  and  citizenship  policies. 

* ^ * 

To  the  peoples  and  governments  beyond 
our  shores  we  offer  the  following  pledges: 

The  Underdeveloped  World 

To  the  non-Communist  nations  of  Asia,  Af- 
rica, and  Latin  America:  we  shall  create  with 
you  working  partnerships,  based  on  mutual 
respect  and  understanding. 

In  the  Jeffersonian  tradition,  we  recognize 
and  welcome  the  irresistible  momentum  of 
the  world  revolution  of  rising  expectations 
for  a better  life.  We  shall  identify  American 
policy  with  its  values  and  objectives. 

To  this  end  the  new  Democratic  adminis- 
tration will  revamp  and  refocus  the  objec- 
tives, emphasis  and  allocation  of  our  foreign 
assistance  programs. 

The  proper  purpose  of  these  programs  is 
not  to  buy  gratitude  or  to  recruit  merce- 
naries. but  to  enable  the  peoples  of  these 
awakening,  developing  nations  to  make  their 
own  free  choices. 


SEPTEMBER  I960— VOL.  30,  NO.  3 


155 


THE  ASSOCIATION  FORUM 


As  they  achieve  a sense  of  belonging,  of 
dignity,  and  of  justice,  freedom  will  become 
meaningful  for  them,  and  therefore  worth  de- 
fending. 

Where  military  assistance  remains  essential 
for  the  common  defense,  we  shall  see  that  the 
requirements  are  fully  met.  But  as  rapidly 
as  security  considerations  permit,  we  will  re- 
place tanks  with  tractors,  bombers  with  bull- 
dozers, and  tacticians  with  technicians. 

We  shall  place  our  programs  of  internation- 
al cooperation  on  a long-term  basis  to  per- 
mit more  effective  planning.  We  shall  seek 
to  associate  other  capital  exporting  countries 
with  us  in  promoting  the  orderly  economic 
growth  of  the  underdeveloped  world. 

We  recognize  India  and  Pakistan  as  major 
tests  of  the  capacity  of  free  men  in  a difficult 
environment  to  master  the  age-old  problems 
of  illiteracy,  poverty,  and  disease.  We  will 
support  their  efforts  in  every  practical  way. 

We  welcome  the  emerging  new  nations  of 
Africa  to  the  world  community.  Here  again 
we  shall  strive  to  write  a new  chapter  of 
fruitful  cooperation. 

In  Latin  America  we  shall  restore  the  Good 
Neighbor  policy  based  on  far  closer  economic 
cooperation  and  increased  respect  and  under- 
standing. 

In  the  Middle  East  we  will  work  for  guar- 
antees to  insure  independence  for  all  states. 
We  will  encourage  direct  Arab-Israel  peace 
negotiations,  the  resettlement  of  Arab  refu- 
gees in  lands  where  there  is  room  and  oppor- 
tunity for  them,  an  end  to  boycotts  and  block- 
ades, and  unrestricted  use  of  the  Suez  Canal 
by  all  nations. 

A billion  and  a half  people  in  Asia,  Africa 
and  Latin  America  are  engaged  in  an  unprec- 
edented attempt  to  propel  themselves  into 
the  twentieth  century.  They  are  striving  to 
create  or  reaffirm  their  national  identity. 

But  they  want  much  more  than  independ- 
ence. They  want  an  end  to  grinding  poverty. 
They  want  more  food,  health  for  themselves 
and  their  children  and  other  benefits  that  a 
modern  industrial  civilization  can  provide. 


Communist  strategy  has  sought  to  divert 
these  aspirations  into  narrowly  nationalistic 
channels,  or  external  trouble-making  or  au- 
thoritarianism. The  Republican  administra- 
tion has  played  into  the  hands  of  this  strategy 
by  concerning  itself  almost  exclusively  with 
the  military  problem  of  Communist  invasion. 

The  Democratic  programs  of  economic  co- 
operation will  be  aimed  at  making  it  as  easy 
as  possible  for  the  political  leadership  in  these 
countries  to  turn  the  energy,  talent  and  re- 
sources of  their  peoples  to  orderly  economic 
growth. 

History  and  current  experience  show  that 
an  annual  per  capita  growth  rate  of  at  least 
2 per  cent  is  feasible  in  these  countries.  The 
Democratic  administration’s  assistance  pro- 
gram, in  concert  with  the  aid  forthcoming 
from  our  partners  in  Western  Europe,  Japan, 
and  the  British  Commonwealth,  will  be  gear- 
ed to  facilitating  this  objective. 

The  Democratic  administration  will  recog- 
nize that  assistance  to  these  countries  is  not 
an  emergency  or  short-term  matter.  Through 
the  Development  Loan  Fund  and  otherwise, 
we  shall  seek  to  assure  continuity  in  our  aid 
programs  for  periods  of  at  least  five  years,  to 
permit  more  effective  allocation  on  our  part 
and  better  planning  by  the  governments  of 
the  countries  receiving  aid. 

More  effective  use  of  aid  and  a greater  con- 
fidence in  us  and  our  motives  will  be  the  re- 
sult. 

We  will  establish  priorities  for  foreign  aid 
which  will  channel  it  to  those  countries 
abroad  which,  by  their  own  willingness  to 
help  themselves,  show  themselves  most  cap- 
able of  using  it  effectively. 

We  will  use  our  own  agricultural  produc- 
tivity as  an  effective  tool  of  foreign  aid,  and 
also  as  a vital  form  of  working  capital  for 
economic  development.  We  shall  seek  new 
approaches  which  will  provide  assistance 
without  disrupting  normal  world  markets  for 
food  and  fiber. 

We  shall  give  attention  to  the  problem  of 
stabilizing  world  prices  of  agricultural  com- 
modities and  basic  raw  materials  on  which 


156 


J.  M.  A.  ALABAMA 


THE  ASSOCIATION  FORUM 


many  underdeveloped  countries  depend  for 
needed  foreign  exchange. 

We  shall  explore  the  feasibility  of  shipping 
and  storing  a substantial  part  of  our  food 
abundance  in  a system  of  “food  banks”  located 
in  distribution  centers  in  the  underdeveloped 
world. 

Such  a system  would  be  an  effective  means 
of  alleviating  famine  and  suffering  in  times 
of  natural  disaster,  and  of  cushioning  the  ef- 
fect of  bad  harvests.  It  would  also  have  a 
helpful,  anti-inflationary  influence  as  eco- 
nomic development  gets  underway. 

Although  basic  development  requirements 
like  transport,  housing,  schools,  and  river  de- 
velopment, may  be  financed  by  government, 
these  projects  are  usually  built  and  some- 
times managed  by  private  enterprise.  More- 
over, outside  this  public  sector  a large  in- 
creasing role  remains  for  private  investment. 

The  Republican  administration  has  done 
little  to  summon  American  business  to  play 
its  part  in  this,  one  of  the  most  creative  tasks 
of  our  generation.  The  Democratic  adminis- 
tration will  take  steps  to  recruit  and  organ- 
ize effectively  the  best  business  talent  in 
America  for  foreign  economic  development. 

We  urge  continued  economic  assistance  to 
Israel  and  the  Arab  peoples  to  help  them 
raise  their  living  standards.  We  pledge  our 
best  efforts  for  peace  in  the  Middle  East  by 
seeking  to  prevent  an  arms  race  while  guard- 
ing against  the  dangers  of  a military  imbal- 
ance resulting  from  Soviet  arms  shipments. 

The  Atlantic  Community 

To  our  friends  and  associates  in  the  Atlantic 
Community:  we  propose  a broader  partner- 
ship that  goes  beyond  our  common  fears,  to 
recognize  the  depth  and  sweep  of  our  com- 
mon political,  economic,  and  cultural  inter- 
ests. 

We  welcome  the  recent  heartening  ad- 
vances toward  European  unity.  In  every  ap- 
propriate way.  we  shall  encourage  their  fur- 
ther growth  within  the  broader  framework  of 
the  Atlantic  Community. 


After  World  War  II,  the  vision  of  Demo- 
cratic statesmen  saw  that  an  orderly  peaceful 
world  was  impossible  with  Europe  shattered 
and  exhausted. 

They  fashioned  the  great  programs  which 
bear  their  names — the  Truman  Doctrine  and 
the  Marshall  Plan — by  which  the  economies 
of  Europe  were  revived.  Then  in  NATO  they 
renewed  for  the  common  defense  the  ties  of 
alliance  forged  in  war. 

In  these  endeavors,  the  Democratic  admin- 
istrations invited  leading  Republicans  to  full 
participation  as  equal  partners.  But  the  Re- 
publican administration  has  rejected  this 
principle  of  bi-partisanship. 

We  have  already  seen  how  the  mutual  trust 
and  confidence  created  abroad  under  Demo- 
cratic leadership  has  been  eroded  by  arro- 
gance, clumsiness,  and  lack  of  understanding 
in  the  Republican  administration. 

The  new  Democratic  administration  will  re- 
store the  former  high  levels  of  cooperation 
within  the  Atlantic  community  envisaged 
from  the  beginning  by  the  NATO  treaty  in 
political  and  economic  spheres  as  well  as  mili- 
tary affairs. 

We  welcome  the  progress  towards  Euro- 
pean unity  expressed  in  the  Coal  and  Steel 
Community,  Euratom,  the  European  Eco- 
nomic Community,  The  European  Free  Trade 
Association,  and  the  European  Assembly. 

We  shall  conduct  our  relations  with  the  na- 
tions of  the  Common  Market  so  as  to  encour- 
age the  opportunities  for  freer  and  more  ex- 
panded trade,  and  to  avert  the  possibilities  of 
discrimination,  inherent  in  it. 

We  shall  encourage  adjustment  with  the 
so-called  “outer  seven”  nations  so  as  to  furth- 
er enlarge  the  area  of  freer  trade. 

The  Communist  World 

To  the  rulers  of  the  Communist  World:  We 
confidently  accept  your  challenge  to  compe- 
tition in  every  field  of  human  effort. 

We  recognize  this  contest  as  one  between 
two  radically  different  approaches  to  the 


SEPTEMBER  I960— VOL.  30,  NO.  3 


157 


THE  ASSOCIATION  FORUM 


meaning  of  life — our  open  society  which 
places  its  highest  value  upon  individual  dig- 
nity, and  your  closed  society  in  which  the 
rights  of  men  are  sacrificed  to  the  state. 

We  believe  your  Communist  ideology  to  be 
sterile,  unsound,  and  doomed  to  failure.  We 
believe  that  your  children  will  reject  the  in- 
tellectual prison  in  which  you  seek  to  confine 
them  and  that  ultimately  they  will  choose  the 
eternal  principles  of  freedom. 

In  the  meantime,  we  are  prepared  to  nego- 
tiate with  you  whenever  and  wherever  there 
is  a realistic  possibility  of  progress  without 
sacrifice  of  principle. 

If  negotiations  through  diplomatic  chan- 
nels provide  opportunities,  we  will  negotiate. 

If  debate  before  the  United  Nations  holds 
promise,  we  will  debate. 

If  meetings  at  high  level  offer  prospects  of 
success,  we  will  be  there. 

But  we  will  use  all  the  will,  power,  re- 
sources, and  energy  at  our  command  to  resist 
the  further  encroachment  of  Communism  on 
freedom — whether  at  Berlin.  Formosa  or  new 
points  of  pressure  as  yet  undisclosed. 

We  shall  keep  open  the  lines  of  communi- 
cation with  our  opponents.  Despite  difficul- 
ties in  the  way  of  peaceful  agreement,  every 
useful  avenue  will  be  energetically  explored 
and  pursued. 

However,  we  will  never  surrender  positions 
which  are  essential  to  the  defense  of  freedom, 
nor  will  we  abandon  peoples  who  are  now 
behind  the  Iron  Curtain  through  any  formal 
approval  of  the  status  quo. 

Everyone  proclaims  “firmness”  in  support 
of  Berlin.  The  issue  is  not  the  desire  to  be 
firm,  but  the  capability  to  be  firm.  This,  the 
Democratic  Party  will  provide  as  we  have 
done  before. 

The  ultimate  solution  of  the  situation  in 
Berlin  must  be  approached  in  the  broader 
context  of  settlement  of  the  tensions  and  di- 
visions of  Europe. 

The  good  faith  of  the  United  States  is) 
pledged  likewise  to  defending  Formosa.  We 
will  carry  out  that  pledge. 


The  new  Democratic  administration  will 
also  reaffirm  our  historic  policy  of  opposition 
to  the  establishment  anywhere  in  the  Ameri- 
cas of  governments  dominated  by  foreign 
powers,  a policy  now  being  undermined  by 
Soviet  threats  to  the  freedom  and  independ- 
ence of  Cuba.  The  government  of  the  United 
States  under  a Democratic  administration 
will  not  be  deterred  from  fulfilling  its  obliga- 
tions and  solemn  responsibilities  under  its 
treaties  and  agreements  with  the  nations  of 
the  Western  hemisphere.  Nor  will  the  United 
States,  in  conformity  with  its  treaty  obliga- 
tions, permit  the  establishment  of  a regime 
dominated  by  international,  atheistic  commu- 
nism in  the  Western  hemisphere. 

To  the  people  who  live  in  the  Communist 
world  and  its  captive  nations:  we  proclaim  an 
enduring  friendship  which  goes  beyond  gov- 
ernments and  ideologies  to  our  common  hu- 
man interest  in  a better  world. 

Through  exchanges  of  persons,  cultural 
contacts,  trade  in  non-strategic  areas,  and 
other  non-governmental  activities.,  we  will 
endeavor  to  preserve  and  improve  opportun- 
ities for  human  relationships  which  no  Iron 
Curtain  can  permanently  sever. 

No  political  plat  'orm  promise  in  history 
was  more  cruelly  cynical  than  the  Republican 
effort  to  buy  votes  in  1952  with  false  promises 
of  painless  liberation  for  the  captive  nations. 

The  blood  of  heroic  freedom  fighters  in 
Hungary  tragically  proved  this  promise  a 
fraud.  We  Democrats  will  never  be  party  to 
such  cruel  cultivation  of  false  hopes. 

We  look  forward  to  the  day  when  the  men 
and  women  of  Albania,  Bulgaria,  Czecho- 
slovakia, East  Germany,  Estonia,  Hungary, 
Latvia,  Lithuania,  Poland,  Romania,  and  the 
other  captive  nations  will  stand  again  in  free- 
dom and  justice.  We  will  hasten,  by  every 
honorable  and  responsible  means,  the  arrival 
of  the  day. 

We  shall  never  accept  any  deal  or  arrange- 
ment which  acquiesces  in  the  present  subju- 
gation of  these  peoples. 

We  deeply  regret  that  the  policies  and  ac- 
tions of  the  government  of  Communist  China 


158 


J.  M.  .A.  ALABAMA 


THE  ASSOCIATION  FORUM 


have  interrupted  the  generations  of  friend- 
ship between  the  Chinese  and  American  peo- 
ples. 

We  reaffirm  our  pledge  of  determined  op- 
position to  the  present  admission  of  Commu- 
nist China  to  the  United  Nations. 

Although  normal  diplomatic  relations  be- 
tween our  governments  are  impossible  under 
present  conditions,  we  shall  welcome  any 
evidence  that  the  Chinese  Communist  gov- 
ernment is  genuinely  prepared  to  create  a 
new  relationship  based  on  respect  for  inter- 
national obligations,  including  the  release  of 
American  prisoners. 

The  United  Nations 

To  all  our  fellow  members  of  the  United 
Nations:  we  shall  strengthen  our  commit- 
ments in  this,  our  great  continuing  institution 
for  conciliation  and  the  growth  of  a world 
community. 

Through  the  machinery  of  the  United  Na- 
tions, we  will  work  for  disarmament,  the 
establishment  of  an  international  police 
force,  the  strengthening  of  the  world  court, 
and  the  establishment  of  world  law. 

We  shall  propose  the  bolder  and  more  ef- 
fective use  of  the  specialized  agencies  to  pro- 
mote the  world's  economic  and  social  devel- 
opment. 

Great  Democratic  presidents  have  taken  the 
lead  in  the  effort  to  unite  the  nations  of  the 
world  in  an  international  organization  to  as- 
sure world  peace  with  justice  under  law. 

The  League  of  Nations,  conceived  by  Wood- 
row  Wilson,  was  doomed  by  Republican  de- 
feat of  United  States  participation. 

The  United  Nations,  sponsored  by  Franklin 
Roosevelt,  has  become  the  one  place  where 
representatives  of  the  rival  systems  and  inter- 
ests which  divide  the  world  can  and  do  main- 
tain continuous  contact. 

The  United  States  adherence  to  the  World 
Court  contains  a so-called  “self-judging  reser- 
vation” which,  in  effect,  permits  us  to  prevent 
a Court  decision  in  any  particular  case  in 


which  we  are  involved.  The  Democratic  Par- 
ty proposes  its  repeal. 

To  all  these  endeavors  so  essential  to  world 
peace,  we,  the  members  of  the  Democratic 
Party,  will  bring  a new  urgency,  persistence, 
and  determination,  born  of  the  conviction 
that  in  our  thermonuclear  century,  all  of  the 
other  Rights  of  Man  hinge  on  our  ability  to 
assure  man's  right  to  peace. 


Ill 

The  pursuit  of  peace,  our  contribution  to 
the  stability  of  the  new  nations  of  the  world, 
our  hopes  for  progress  and  well-being  at 
home,  all  these  depend  in  large  measure  on 
our  ability  to  release  the  full  potential  of  our 
American  economy  for  employment,  produc- 
tion, and  growth. 

Our  generation  of  Americans  has  achieved 
an  historic  technological  breakthrough.  To- 
day we  are  capable  of  creating  an  abundance 
in  goods  and  services  beyond  the  dreams  of 
our  parents.  Yet  on  the  threshold  of  plenty, 
the  Republican  administration  hesitates,  con- 
fused and  afraid. 

As  a result,  massive  human  needs  now  ex- 
ist side  by  side  with  idle  workers,  idle  capi- 
tal, and  idle  machines. 

The  Republican  failure  in  the  economic 
field  has  been  virtually  complete. 

Their  years  of  power  have  consisted  of  two 
recessions,  in  1953-54  and  1957-60,  separated 
by  the  most  severe  peacetime  inflation  in  his- 
tory. 

They  have  shown  themselves  incapable  of 
checking  inflation.  In  their  efforts  to  do  so, 
they  have  brought  on  recessions  that  have 
thrown  millions  of  Americans  out  of  work. 
Yet  even  in  these  slumps,  the  cost  of  living 
has  continued  to  climb,  and  it  is  now  at  an 
all-time  high. 

They  have  slowed  down  the  rate  of  growth 
of  the  economy  to  about  one-third  the  rate  of 
the  Soviet  Union. 


SEPTEMBER  I960— VOL.  30,  NO.  3 


159 


THE  ASSOCIATION  FORUM 


Over  the  past  7'/j-year  period,  the  Repub- 
licans have  failed  to  balance  the  budget  or 
reduce  the  national  debt.  Responsible  fiscal 
policy  requires  surpluses  in  good  times  to 
more  than  offset  the  deficits  which  may  occur 
in  recessions,  in  order  to  reduce  the  national 
debt  over  the  long  run.  The  Republican  ad- 
ministration has  produced  the  deficits — in 
fact,  the  greatest  deficit  in  any  peacetime  year 
in  history,  in  1958-59 — but  not  the  surpluses. 
Consequently,  their  seven  years  have  pro- 
duced a total  deficit  of  $19  billion. 

While  reducing  outlays  for  essential  public 
services  which  directly  benefit  our  people, 
they  have  raised  the  annual  interest  charge 
on  the  national  debt  to  a level  $3  billion  high- 
er than  when  they  took  office.  In  the  eight 
fiscal  years  of  the  Republican  administration, 
these  useless  higher  interest  payments  will 
have  cost  the  taxpayers  $9  billion. 

They  have  mismanaged  the  public  debt  not 
only  by  increasing  interest  rates,  but  also  by 
failing  to  lengthen  the  average  maturity  of 
government  obligations  when  they  had  a 
clear  opportunity  to  do  so. 

Economic  Growth 

The  new  Democratic  administration  will 
confidently  proceed  to  unshackle  American 
enterprise  and  to  free  American  labor,  indus- 
trial leadership,  and  capital,  to  create  an 
abundance  that  will  outstrip  any  other  sys- 
tem. 

Free  competitive  enterprise  is  the  most  cre- 
ative and  productive  form  of  economic  order 
that  the  world  has  seen.  The  recent  slow 
pace  of  American  growth  is  due  not  to  the 
failure  of  our  free  economy  but  to  the  failure 
of  our  national  leadership. 

We  Democrats  believe  that  our  economy 
can  and  must  grow  at  an  average  rate  of  5 
per  cent  annually,  almost  twice  as  fast  as  our 
average  annual  rate  since  1953.  We  pledge 
ourselves  to  policies  that  will  achieve  this 
goal  without  inflation. 

Economic  growth  is  the  means  whereby  we 
improve  the  American  standard  of  living  and 


produce  added  tax  resources  for  national  se- 
curity and  essential  public  services. 

Our  economy  must  grow  more  swiftly  in 
order  to  absorb  two  groups  of  workers:  the 
much  larger  number  of  young  people  who 
will  be  reaching  working  age  in  the  1960’s, 
and  the  workers  displaced  by  the  rapid  pace 
of  technological  advances  and  automation. 
Republican  policies  which  have  stifled 
growth  could  only  mean  increasingly  severe 
unemployment,  particularly  of  youth  and  old- 
er workers. 

An  End  to  Tight  Money 

As  the  first  step  in  speeding  economic 
growth,  a Democratic  President  will  put  an 
end  to  the  present  high  interest,  tight  money 
policy. 

This  policy  has  failed  in  its  stated  purpose 
— to  keep  prices  down.  It  has  given  us  two 
recessions  within  five  years,  bankrupted 
many  of  our  farmers,  produced  a record  num- 
ber of  business  failures,  and  added  billions  of 
dollars  in  unnecessary  higher  interest  charges 
to  government  budgets  and  the  cost  of  living. 

A new  Democratic  administration  will  re- 
ject this  philosophy  of  economic  slowdown. 
We  are  committed  to  maximum  employment, 
at  decent  wages  and  v/ith  fair  profits,  in  a far 
more  productive,  expanding  economy. 

The  Republican  high  interest  policy  has  ex- 
tracted a costly  toll  from  every  American 
who  has  financed  a home,  an  automobile,  a 
refrigerator,  or  a television  set. 

It  has  foisted  added  burdens  on  taxpayers 
of  state  and  local  governments  which  must 
borrow  for  schools  and  other  public  services. 

It  has  added  to  the  cost  of  many  goods  and 
services,  and  hence  has  been  itself  a factor 
in  inflation. 

It  has  created  windfalls  for  many  financial 
institutions. 

The  $9  billion  of  added  interest  charges  on 
the  national  debt  would  have  been  even  high- 
er but  for  the  prudent  insistence  of  the  Demo- 
cratic Congress  on  maintaining  the  ceiling  on 


160 


J.  M.  A.  .ALABAMA 


THE  ASSOCIATION  FORUM 


interest  rates  for  long-term  government 
bonds. 

Control  of  Inflation 

The  American  consumer  has  a right  to  fair 
prices.  We  are  determined  to  secure  that 
right. 

Inflation  has  its  roots  in  a variety  of  causes; 
its  cure  lies  in  a variety  of  remedies.  Among 
those  remedies  are  monetary  and  credit  poli- 
cies properly  applied,  budget  surpluses  in 
times  of  full  employment,  and  action  to  re- 
strain "administered  price"  increases  in  in- 
dustries where  economic  power  rests  in  the 
hands  of  a few. 

A fair  share  of  the  gains  from  increasing 
productivity  in  many  industries  should  be 
passed  on  to  the  consumer  through  price  re- 
ductions. 

The  agenda  which  a new  Democratic  ad- 
ministration will  face  next  January  is  crowd- 
ed with  urgent  needs  on  which  action  has 
been  delayed,  deferred,  or  denied  by  the  pres- 
ent Administration. 

A new  Democratic  administration  will  un- 
dertake to  meet  those  needs. 

It  will  reaffirm  the  Economic  Bill  of  Rights 
which  Franklin  Roosevelt  wrote  into  our  na- 
tional conscience  sixteen  years  ago.  It  will 
reaffirm  these  rights  for  all  Americans  of 
whatever  race,  place  of  residence,  or  station 
in  life. 

1.  “The  right  to  a useful  and  remunera- 
tive job  in  the  industries  or  shops  or  farms 

or  mines  of  the  nation.” 

Full  Employment 

The  Democratic  Party  reaffirms  its  support 
of  full  employment  as  a paramount  objective 
of  national  policy. 

For  nearly  30  months  the  rate  of  unemploy- 
ment has  been  between  5 and  7.5%  of  the  la- 
bor force.  A pool  of  3 to  4 million  citizens, 
able  and  willing  to  work  but  unable  to  find 
jobs,  has  been  written  off  by  the  Republican 


administration  as  a “normal”  re-adjustment 
of  the  economic  system. 

The  policies  of  a Democratic  administration 
to  restore  economic  growth  will  reduce  cur- 
rent unemployment  to  a minimum. 

Thereafter,  if  recessionary  trends  appear, 
we  will  act  promptly  with  counter-measures, 
such  as  public  works  or  temporary  tax  cuts. 
We  will  not  stand  idly  by  and  permit  reces- 
sions to  run  their  course  as  the  Republican 
administration  has  done. 

Aid  to  Depressed  Areas 

The  right  to  a job  requires  action  to  create 
new  industry  in  America's  depressed  areas  of 
chronic  unemployment. 

General  economic  measures  will  not  alone 
solve  the  problems  of  localities  which  suffer 
some  special  disadvantage.  To  bring  pros- 
perity to  these  depressed  areas  and  to  enable 
them  to  make  their  full  contribution  to  the 
national  welfare,  specially  directed  action  is 
needed. 

Areas  of  heavy  and  persistent  unemploy- 
ment result  from  depletion  of  natural  re- 
sources, technological  change,  shifting  de- 
fense requirements,  or  trade  imbalances 
which  have  caused  the  decline  of  major  in- 
dustries. Whole  communities,  urban  and  ru- 
ral, have  been  left  stranded  in  distress  and 
despair,  through  no  fault  of  their  own. 

These  communities  have  undertaken  val- 
iant efforts  of  self-help.  But  mutual  aid,  as 
well  as  self-help,  is  part  of  the  American  tra- 
dition. Stricken  communities  deserve  the 
help  of  the  whole  nation. 

The  Democratic  Congress  twice  passed  bills 
to  provide  this  help.  The  Republican  Presi- 
dent twice  vetoed  them. 

These  bills  proposed  low-interest  loans  to 
private  enterprise  to  create  new  industry  and 
new  jobs  in  depressed  communities,  assist- 
ance to  the  communities  to  provide  public 
facilities  necessary  to  encourage  the  new  in- 
dustry, and  re-training  of  workers  for  the 
new  jobs. 


SEPTEMBER  I960— VOL.  30,  NO.  3 


161 


THE  ASSOCIATION  FORUM 


The  Democratic  Congress  will  again  pass, 
and  the  Democratic  President  will  sign,  such 
a bill. 

Discrimination  in  Employment 

The  right  to  a job  requires  action  to  break 
down  artificial  and  arbitrary  barriers  to  em- 
ployment based  on  age,  race,  sex,  religion,  or 
national  origin. 

Unemployment  strikes  hardest  at  workers 
over  40,  minority  groups,  young  people,  and 
women.  We  will  not  achieve  full  employ- 
ment until  prejudice  against  these  workers  is 
wiped  out. 

Collective  Bargaining 

The  right  to  a job  requires  the  restoration 
of  full  support  for  collective  bargaining  and 
the  repeal  of  the  anti-labor  excesses  which 
have  been  written  into  our  labor  laws. 

Under  Democratic  leadership  a sound  na- 
tional policy  was  developed,  expressed  par- 
ticularly by  the  Wagner  National  Labor  Rela- 
tions Act,  which  guaranteed  the  rights  of 
workers  to  organize  and  to  bargain  collec- 
tively. But  the  Republican  administration 
has  replaced  this  sound  policy  with  a national 
anti-labor  policy. 

The  Republican  Taft-Hartley  Act  seriously 
weakened  unions  in  their  efforts  to  bring  eco- 
nomic justice  to  the  millions  of  American 
workers  who  remain  unorganized. 

By  administrative  action,  anti-labor  person- 
nel appointed  by  the  Republicans  to  the  Na- 
tional Labor  Relations  Board  have  made  the 
Taft-Hartley  Act  even  more  restrictive  in  its 
application  than  in  its  language. 

Thus  the  traditional  goal  of  the  Democratic 
Party — to  give  all  workers  the  right  to  or- 
ganize and  bargain  collectively — has  still  not 
been  achieved. 

We  pledge  the  enactment  of  an  affirmative 
labor  policy  which  will  encourage  free  col- 
lective bargaining  through  the  growth  and 
development  of  free  and  responsible  unions. 


Millions  of  workers  just  now  seeking  to 
organize  are  blocked  by  federally-authorized 
“right-to-work”  laws,  unreasonable  limita- 
tions on  the  right  to  picket,  and  other  ham- 
pering legislative  and  administrative  pro- 
visions. 

Again,  in  the  new  Labor-Management  Re- 
porting and  Disclosure  Act,  the  Republican 
administration  perverted  the  constructive  ef- 
fort of  the  Democratic  Congress  to  deal  with 
improper  activities  of  a few  in  labor  and 
management  by  turning  that  Act  into  a means 
of  restricting  the  legitimate  rights  of  the  vast 
majority  of  working  men  and  women  in  hon- 
est labor  unions.  This  law  likewise  strikes 
hardest  at  the  weak  or  poorly  organized,  and 
it  fails  to  deal  with  equal  vigor  with  abuses 
of  management  as  well  as  those  of  labor. 

We  will  repeal  the  authorization  for  “right- 
to-work”  laws,  limitations  on  the  right  to 
strike,  to  picket  peacefully  and  to  tell  the 
public  the  facts  of  a labor  dispute,  and  other 
anti-labor  features  of  the  Taft-Hartley  Act 
and  the  1959  Act.  This  unequivocal  pledge 
for  the  repeal  of  the  anti-labor  and  restrictive 
provisions  of  those  laws  will  encourage  col- 
lective bargaining  and  strengthen  and  sup- 
port the  free  and  honest  labor  movement. 

The  Railroad  Retirement  Act  and  the  Rail- 
road Unemployment  Insurance  Act  are  in 
need  of  improvement.  We  strongly  oppose 
Republican  attempts  to  weaken  the  Railway 
Labor  Act. 

We  shall  strengthen  and  modernize  the 
Walsh-Healey  and  Davis-Bacon  Acts,  which 
protect  the  wage  standards  of  workers  em- 
ployed by  government  contractors. 

Basic  to  the  achievement  of  stable  labor- 
management  relations  is  leadership  from  the 
White  House.  The  Republican  administration 
has  failed  to  provide  such  leadership. 

They  failed  to  foresee  the  deterioration  of 
labor-management  relations  in  the  steel  in- 
dustry last  year.  When  it  became  obvious 
that  a national  emergency  was  developing, 
they  failed  to  forestall  it.  When  it  came,  their 
only  solution  was  government-by-injunction. 


162 


J.  M.  A.  ALABAMA 


THE  ASSOCIATION  FORUM 


A Democratic  President,  through  his  lead- 
ership and  concern,  will  produce  a better  cli- 
mate for  continuing  constructive  relation- 
ships between  labor  and  management.  He  will 
have  periodic  White  House  conferences  be- 
tween labor  and  management  to  consider 
their  mutual  problems  before  they  reach  the 
critical  stage. 

A Democratic  President  will  use  the  vast 
fact-finding  facilities  that  are  available  to  in- 
form himself,  and  the  public,  in  exercising  his 
leadership  in  labor  disputes  for  the  benefit  of 
the  nation  as  a whole. 

If  he  needs  more  such  facilities,  or  authori- 
ty, we  will  provide  them. 

We  further  pledge  that  in  the  administra- 
tion of  all  labor  legislation  we  will  restore  the 
level  of  integrity,  competence  and  sympa- 
thetic understanding  required  to  carry  out 
the  intent  of  such  legislation. 

Planning  for  Automation 

The  right  to  a job  requires  planning  for 
automation,  so  that  men  and  women  will  be 
trained  and  available  to  meet  shifting  em- 
ployment needs. 

We  will  conduct  a continuing  analysis  of 
the  nation’s  manpower  resources  and  of  meas- 
ures which  may  be  required  to  assure  their 
fullest  development  and  use. 

We  will  provide  the  government  leadership 
necessary  to  insure  that  the  blessings  of  auto- 
mation do  not  become  burdens  of  widespread 
unemployment.  For  the  young  and  the  tech- 
nologically displaced  workers,  we  will  provide 
the  opportunity  for  training  and  retraining 
that  equips  them  for  jobs  to  be  filled. 

Minimum  Wages 

2.  “The  right  to  earn  enough  to  provide 

adequate  food  and  clothing  and  recreation.” 

At  the  bottom  of  the  income  scale  are  some 
eight  million  families  whose  earnings  are  too 
low  to  provide  even  basic  necessities  of  food, 
shelter,  and  clothing. 

SEPTEMBER  I960— VOL.  30,  NO.  3 


We  pledge  to  raise  the  minimum  wage  to 
$1.25  an  hour  and  to  extend  coverage  to  sev- 
eral million  workers  not  now  protected. 

We  pledge  further  improvements  in  the 
wage,  hour  and  coverage  standards  of  the 
Fair  Labor  Standards  Act  so  as  to  extend  its 
benefits  to  all  workers  employed  in  indus- 
tries engaged  in  or  affecting  interstate  com- 
merce and  to  raise  its  standards  to  keep  up 
with  our  general  economic  progress  and 
needs. 

We  shall  seek  to  bring  the  2 million  men, 
women  and  children  who  work  for  wages  on 
the  farms  of  the  United  States  under  the  pro- 
tection of  existing  labor  and  social  legislation; 
and  to  assure  migrant  labor,  perhaps  the  most 
underprivileged  of  all,  of  a comprehensive 
program  to  bring  them  not  only  decent  wages 
but  also  an  adequate  standard  of  health,  hous- 
ing, Social  Security  protection,  education  and 
welfare  services. 


Agriculture 

3.  “The  right  of  every  farmer  to  raise 

and  sell  his  products  at  a return  which  will 

give  him  and  his  family  a decent  living.” 

We  shall  take  positive  action  to  raise  farm 
income  to  full  parity  levels  and  to  preserve 
family  farming  as  a way  of  life. 

We  shall  put  behind  us  once  and  for  all  the 
timidity  with  which  our  government  has 
viewed  our  abundance  of  food  and  fiber. 

We  will  set  new  high  levels  of  food  con- 
sumption both  at  home  and  abroad. 

As  long  as  many  Americans  and  hundreds 
of  millions  of  people  in  other  countries  remain 
underfed,  we  shall  regard  these  agricultural 
riches,  and  the  family  farmers  who  produce 
them,  not  as  a liability  but  as  a national  asset. 

Using  Our  Abundance.  The  Democratic  ad- 
ministration will  inaugurate  a national  food 
and  fiber  policy  for  expanded  use  of  our  agri- 
cultural abundance.  We  will  no  longer  view 
food  stockpiles  with  alarm  but  will  use  them 
as  powerful  instruments  for  peace  and  plenty. 

163 


THE  ASSOCIATION  FORUM 


We  will  increase  consumption  at  home.  A 
vigorous  expanding  economy  will  enable 
many  American  families  to  eat  more  and  bet- 
ter food. 

We  will  use  the  food  stamp  programs  auth- 
orized to  feed  needy  children,  aged  and  un- 
employed. We  will  expand  and  improve  the 
school  lunch  and  milk  programs. 

We  will  establish  and  maintain  a food  re- 
serve for  national  defense  purposes  near  im- 
portant population  centers  to  preserve  lives 
in  event  of  national  disaster,  operated  so  as 
not  to  depress  farm  prices.  We  will  expand 
research  into  new  industrial  uses  of  agricul- 
tural products. 

We  will  increase  consumption  abroad.  The 
Democratic  Party  believes  our  nation’s  ca- 
pacity to  produce  food  and  fiber  is  one  of  the 
great  weapons  for  waging  war  against  hunger 
and  want  throughout  the  world.  With  wise 
management  of  our  food  abundance  we  will 
expand  trade  between  nations,  support  eco- 
nomic and  human  development  programs  and 
combat  famine. 

Unimaginative,  outmoded  Republican  pol- 
icies which  fail  to  use  these  productive  ca- 
pacities of  our  farms  have  been  immensely 
costly  to  our  nation.  They  can  and  will  be 
changed. 

Achieving  Income  Parity.  While  farmers 
have  raised  their  productive  efficiency  to  rec- 
ord levels,  Republican  farm  policies  forced 
their  income  to  drop  by  30  per  cent  over  the 
past  eight  years. 

Tens  of  thousands  of  farm  families  have 
been  banki'upted  and  forced  off  the  land.  And 
this  despite  the  fact  that  the  Secretary  of 
Agriculture  has  spent  more  on  farm  programs 
than  all  previous  Secretaries  in  history  com- 
bined. 

Farmers  acting  individually  or  in  small 
groups  are  helpless  to  protect  their  incomes 
from  sharp  declines.  Their  only  recourse  is 
to  produce  more,  throwing  production  still 
further  out  of  balance  with  demand  and  driv- 
ing prices  down  further. 


This  disastrous  downward  cycle  can  be 
stopped  only  by  effective  farm  programs  sym- 
pathetically administered  with  the  assistance 
of  democratically  elected  farmer  committees. 

The  Democratic  administration  will  work 
to  bring  about  full  parity  income  for  farmers 
in  all  segments  of  agriculture  by  helping 
them  to  balance  farm  production  with  the  ex- 
panding needs  of  the  nation  and  the  world. 

Measures  to  this  end  include  production 
and  marketing  quotas  measured  in  terms  of 
barrels,  bushels,  and  bales,  loans  on  basic 
commodities  at  not  less  than  90'/f  of  parity, 
production  payments,  commodity  purchases, 
and  marketing  orders  and  agreements. 

We  repudiate  the  Republican  administra- 
tion of  the  Soil  Bank  Program  which  has  em- 
phasized the  retirement  of  whole  farm  units 
and  pledge  an  orderly  land  retirement  and 
conservation  program. 

We  are  convinced  that  a successful  com- 
bination of  these  approaches  will  cost  con- 
siderably less  than  present  Republican  pro- 
grams which  have  failed. 

We  will  encourage  agricultural  coopera- 
tives by  expanding  and  liberalizing  existing 
credit  facilities  and  developing  new  facilities 
if  necessary  to  assist  them  in  extending  their 
marketing  and  purchasing  activities,  and  we 
will  protect  cooperatives  from  punitive  tax- 
ation. 

The  Democratic  administration  will  im- 
prove the  marketing  practices  of  the  family- 
type  dairy  farm  to  reduce  risk  of  loss. 

To  protect  farmers’  incomes  in  times  of  na- 
tural disaster,  the  Federal  Crop  Insurance 
Program,  created  and  developed  experimen- 
tally under  Democratic  administrations, 
should  be  invigorated  and  expanded  nation- 
wide. 

Improving  Working  and  Living  on  Farms. 

Farm  families  have  been  among  those  victim- 
ized most  severely  by  Republican  tight  money 
policies. 

Young  people  have  been  barred  from  enter- 
ing agriculture.  Giant  corporations  and  other 
non-farmers,  with  readier  access  to  credit 


164 


J.  M.  A.  ALABAMA 


THE  ASSOCIATION  FORUM 


and  through  vertical  integration  methods, 
have  supplanted  hundreds  of  farm  families 
and  caused  the  bankruntcy  of  many  others. 

The  Democratic  Party  is  committed  by  tra- 
dition and  conviction  to  preservation  of  fami- 
ly agriculture. 

To  this  end,  we  will  expand  and  liberalize 
farm  credit  facilities,  especially  to  meet  the 
needs  of  family-farm  agriculture  and  to  as- 
sist beginning  farmers. 

Many  families  in  America’s  rural  counties 
are  still  living  in  poverty  because  of  inade- 
quate resources  and  opportunity.  This  blight 
and  personal  desperation  should  have  receiv- 
ed national  priority  attention  long  ago. 

The  new  Democratic  administration  will 
begin  at  once  to  eradicate  long-neglected  ru- 
ral blight.  We  will  help  people  help  them- 
selves with  extended  and  supervised  credit 
for  farm  improvement,  local  industrial  de- 
velopment, improved  vocational  training  and 
other  assistance  to  those  wishing  to  change 
to  non-farm  employment,  and  the  fullest  de- 
velopment of  commercial  recreational  possi- 
bilities. This  is  one  of  the  major  objectives 
of  the  area  redevelopment  program,  twice 
vetoed  by  the  Republican  President. 

The  rural  electric  cooperatives  celebrate 
this  year  the  twenty-fifth  anniversary  of  the 
creation  of  the  Rural  Electrification  Admin- 
istration under  President  Franklin  D.  Roose- 
velt. 

The  Democratic  Congress  has  successfully 
fought  the  efforts  of  the  Republican  adminis- 
tration to  cut  off  REA  loans  and  force  its 
high  interest  rate  policies  on  this  great  rural 
enterprise. 

We  will  maintain  interest  rates  for  REA  co- 
ops and  public  power  districts  at  the  levels 
provided  in  the  present  law. 

We  deplore  administration  failure  to  pro- 
vide the  dynamic  leadership  necessary  to  en- 
courage loans  to  rural  users  for  generation 
of  power  where  necessary. 

We  promise  the  co-ops  active  support  in 
meeting  the  ever-growing  demand  for  electric 
power  and  telephone  service  to  be  filled  on 


a complete  area-coverage  basis,  without  re- 
quiring benefits  for  special  interest  power 
groups. 

In  every  way  we  will  seek  to  help  the  men, 
women,  and  children  whose  livelihood  comes 
from  the  soil  to  achieve  better  housing,  edu- 
cation, health,  and  decent  earnings  and  work- 
ing conditions. 

All  these  goals  demand  the  leadership  of  a 
Secretary  of  Agriculture  who  is  not  only  con- 
versant with  the  technological  and  economic 
aspects  of  farm  problems,  but  who  is  sym- 
pathetic with  the  objectives  of  effective  farm 
legislation  not  only  for  farmers  but  for  the 
best  interest  of  the  nation  as  a whole. 

Small  Business 

4.  “The  right  of  every  businessman,  large 

and  small,  to  trade  in  an  atmosphere  of 

freedom  from  unfair  competition  and  domi- 
nation by  monopolies  at  home  and  abroad.” 

The  new  Democratic  administration  will 
act  to  make  our  free  economy  really  free — 
free  from  the  oppression  of  monopolistic  pow- 
er— free  from  the  suffocating  impact  of  high 
interest  rates.  We  will  help  create  an  econo- 
my in  which  small  businesses  can  take  root, 
grow,  and  flourish. 

We  Democrats  pledge: 

1.  Action  to  aid  small  business  to  obtain 
credit  and  equity  capital  at  reasonable  rates. 
Small  business  which  must  borrow  to  stay 
alive  has  been  a particular  victim  of  the  high 
interest  policies  of  the  Republican  administra- 
tion. 

The  loan  program  of  the  Small  Business 
Administration  should  be  accelerated,  and  the 
independence  of  that  agency  preserved.  The 
Small  Business  Investment  Act  of  1958  must 
be  administered  with  a greater  sense  of  its 
importance  and  possibilities. 

2.  Protection  of  the  public  against  the 
growth  of  monopoly. 

The  last  eight  years  of  Republican  govern- 
ment has  been  the  greatest  period  of  merger 
and  amalgamation  in  industry  and  banking  in 


SEPTEMBER  I960— VOL.  30,  NO.  3 


165 


THE  ASSOCIATION  FORUM 


American  history.  Democratic  Congresses 
have  enacted  numerous  important  measures 
to  strengthen  our  anti-trust  laws.  Since  1950 
the  four  Democratic  Congresses  have  enacted 
laws  like  the  Celler-Kefauver  Anti-merger 
Act,  and  to  improve  the  laws  against  price 
discriminations  and  tie-in  sales. 

When  the  Republicans  were  in  control  of 
the  80th  and  of  the  83rd  Congresses  they  fail- 
ed to  enact  a single  measure  to  strengthen  or 
improve  the  anti-trust  laws. 

The  Democratic  Party  opposes  this  trend 
to  monopoly. 

We  pledge  vigorous  enforcement  of  the 
anti-trust  laws. 

We  favor  requiring  corporations  to  file  ad- 
vance notice  of  mergers  with  the  anti-trust 
enforcement  agencies. 

We  favor  permitting  all  firms  to  have  ac- 
cess at  reasonable  rates  to  patented  inventions 
resulting  from  government  financed  research 
and  development  contracts. 

We  favor  strengthening  the  Robinson-Pat- 
man  Act  to  protect  small  business  against 
price  discrimination. 

We  favor  authorizing  the  Federal  Trade 
Commission  to  obtain  temporary  injunctions 
during  the  pendency  of  administrative  pro- 
ceedings. 

3.  A more  equitable  share  of  government 
contracts  to  small  and  independent  business. 

We  will  move  from  almost  complete  reli- 
ance on  negotiation  in  the  award  of  govern- 
ment contracts  toward  open,  competitive 
bidding. 

Housing 

5.  “The  right  of  every  favrily  to  a decent 

home.” 

Today  our  rate  of  home  building  is  less  than 
ten  years  ago.  A healthy  expanding  econo- 
my will  enable  us  to  build  two  million  homes 
a year,  in  wholesome  neighborhoods.,  for  peo- 
ple of  all  incomes. 

At  this  rate,  within  a single  decade  we  can 
clear  away  our  slums  and  assure  every  Amer- 
ican family  a decent  place  to  live. 


Republican  policies  have  led  to  a decline 
of  the  home  building  industry  and  the  pro- 
duction of  fewer  homes.  Republican  high  in- 
terest policies  have  forced  the  cost  of  decent 
housing  beyond  the  range  of  many  families. 
Republican  indifference  has  perpetuated 
slums. 

We  record  the  unpleasant  fact  that  in  1960 
at  least  40  million  Americans  live  in  substand- 
ard housing. 

One  million  new  families  are  formed  each 
year  and  need  housing,  and  300,000  existing 
homes  need  to  be  replaced.  At  present,  con- 
struction does  not  even  meet  these  require- 
ments, much  less  permit  reduction  of  the 
backlog  of  slum  units. 

We  support  a housing  construction  goal  of 
more  than  2,000,000  homes  a year.  Most  of 
the  increased  construction  will  be  priced  to 
meet  the  housing  needs  of  middle  and  low 
income  families  who  now  live  in  substandard 
housing  and  are  priced  out  of  the  market  for 
decent  homes. 

Our  housing  programs  will  provide  for  ren- 
tal as  well  as  sales  housing.  They  will  permit 
expanded  cooperative  housing  programs  and 
sharply  stepped-up  rehabilitation  of  existing 
homes. 

To  make  possible  the  building  of  2,000,000 
homes  a year  in  wholesome  neighborhoods, 
the  home  building  industry  should  be  aided 
by  special  mortgage  assistance,  with  low  in- 
terest rates,  long-term  mortgage  periods  and 
reduced  down  payments.  Where  necessary, 
direct  government  loans  should  be  provided. 

Even  with  this  new  and  flexible  approach, 
there  will  still  be  need  for  a substantial  low- 
rent  public  housing  program  authorizing  as 
many  units  as  local  communities  require  and 
are  prepared  to  build. 

Health 

6.  “The  right  to  adequate  medical  care 

and  the  opportunity  to  achieve  and  enjoy 

good  health.” 

Illness  is  expensive.  Many  Americans  have 
neither  incomes  nor  insurance  protection  to 


166 


J.  M.  A.  ALABAMA 


THE  ASSOCIATION  FORUM 


enable  them  to  pay  for  modern  health  care. 
The  problem  is  particularly  acute  with  our 
older  citizens,  among  whom  serious  illness 
strikes  most  often. 

We  shall  provide  medical  care  benefits  for 
the  aged  as  part  of  the  time-tested  social  se- 
curity insurance  system.  We  reject  any  pro- 
posal which  would  require  such  citizens  to 
submit  to  the  indignity  of  a means  test — a 
"pauper's  oath." 

For  young  and  old  alike,  we  need  more 
medical  schools,  more  hospitals,  more  re- 
search laboratories  to  speed  the  final  con- 
quest of  major  killers. 

Medical  Care  for  Older  Persons.  Sixty  mil- 
lion Americans — more  than  a third  of  our  peo- 
ple— have  no  insurance  protection  against  the 
high  cost  of  illness.  For  the  rest,  private 
health  insurance  pays,  on  the  average,  only 
about  one-third  of  the  cost  of  medical  care. 

The  problem  is  particularly  acute  among 
the  16  million  Americans  over  65  years  old, 
disabled  workers,  widows  and  orphans. 

Most  of  these  have  low  incomes  and  the 
elderly  among  them  suffer  two  to  three  times 
as  much  illness  as  the  rest  of  the  population. 

The  Republican  administration  refused  to 
acknowledge  any  national  responsibility  for 
health  care  for  elder  citizens  until  forced  to  do 
so  by  an  increasingly  outraged  demand.  Then, 
their  belated  proposal  was  a cynical  sham 
built  around  a degrading  test  based  on  means 
or  income — a “pauper’s  oath.” 

The  most  practicable  way  to  provide  health 
protection  for  older  people  is  to  use  the  con- 
tributory machinery  of  the  social  security 
system  for  insurance  covering  hospital  bills 
and  other  high  cost  medical  services.  For 
those  relatively  few  of  our  older  people  who 
have  never  been  eligible  for  social  security 
coverage,  we  shall  provide  corresponding 
benefits  by  appropriations  from  the  general 
revenue. 

Research.  We  will  step  up  medical  research 
on  the  major  killers  and  crippling  diseases — 
cancer,  heart  disease,  arthritis,  mental  illness. 
Expenditures  for  these  purposes  should  be 
limited  only  by  the  availability  of  personnel 


and  promising  lines  of  research.  Today  such 
illness  costs  us  $35  billion  annually,  much  of 
which  could  be  avoided.  Federal  appropria- 
tions for  medical  research  are  barely  1%  of 
this  amount. 

Heart  disease  and  cancer  together  account 
for  two  out  of  every  three  deaths  in  this  coun- 
try. The  Democratic  President  will  summon 
to  a White  House  conference  the  nation’s 
most  distinguished  scientists  in  these  fields 
to  map  a coordinated  long-run  program  for 
the  prevention  and  control  of  these  diseases. 

We  will  also  support  a cooperative  program 
with  other  nations  on  international  health  re- 
search. 

Hospitals.  We  will  expand  and  improve  the 
Hill-Burton  hospital  construction  program. 

Health  Manpower.  To  ease  the  growing 
shortage  of  doctors  and  other  medical  person- 
nel we  propose  federal  aid  for  constructing, 
expanding  and  modernizing  schools  of  medi- 
cine, dentistry,  nursing  and  public  health. 

We  are  deeply  concerned  that  the  high  cost 
of  medical  education  is  putting  this  profession 
beyond  the  means  of  most  American  families. 
We  will  provide  scholarships  and  other  assist- 
ance to  break  through  the  financial  barriers 
to  medical  education. 

Mental  Health.  Mental  patients  fill  more 
than  half  the  hospital  beds  in  the  country 
today.  We  will  provide  greatly  increased  fed- 
eral support  for  psychiatric  research  and 
training  and  community  mental  health  pro- 
grams to  help  bring  back  thousands  of  our 
hospitalized  mentally  ill  to  full  and  useful 
lives  in  the  community. 

^ Hi 

7.  “The  right  to  adequate  protection  from 

the  economic  fears  of  old  age,  sickness,  ac- 
cidents, and  unemployment.” 


A Program  for  the  Aging 

The  Democratic  administration  will  end  the 
neglect  of  our  older  citizens.  They  deserve 
lives  of  usefulness,  dignity,  independence. 


SEPTEMBER  I960 — VOL.  30.  NO.  3 


167 


THE  ASSOCIATION  FORUM 


and  participation.  We  shall  assure  them  not 
only  health  care  but  employment  for  those 
who  want  work,  decent  housing,  and  recrea- 
tion. 

Already  16  million  Americans — about  one 
in  ten — are  over  65,  with  the  prospect  of  26 
million  by  1980. 

Health.  As  stated,  we  will  provide  an  effec- 
tive system  for  paid-up  medical  insurance 
upon  retirement,  financed  during  working 
years  through  the  social  security  mechanism 
and  available  to  all  retired  persons  without 
a means  test.  This  is  first  priority. 

Income.  Half  of  the  people  over  65  have  in- 
comes inadequate  for  basic  nutrition,  decent 
housing,  minimum  recreation  and  medical 
care.  Older  people  who  do  not  want  to  retire 
need  employment  opportunity  and  those  of 
retirement  age  who  no  longer  wish  to  or  can- 
not work  need  better  retirement  benefits. 

We  pledge  a campaign  to  eliminate  dis- 
crimination in  employment  due  to  age.  As  a 
first  step  we  will  prohibit  such  discrimination 
by  government  contractors  and  subcontrac- 
tors. 

We  will  amend  the  Social  Security  Act  to 
increase  the  retirement  benefit  for  each  ad- 
ditional year  of  work  after  65,  thus  encourag- 
ing workers  to  continue  on  the  job  full  time. 

To  encourage  part-time  work  by  others,  we 
favor  raising  the  $1200  a year  ceiling  on  what 
a worker  may  earn  while  still  drawing  social 
security  benefits. 

Retirement  benefits  must  be  increased  gen- 
erally, and  minimum  benefits  raised  from  $33 
to  $50  a month. 

Housing.  We  shall  provide  decent  and  suit- 
able housing  which  older  persons  can  afford. 
Specifically  we  shall  move  ahead  with  the 
program  of  direct  government  loans  for  hous- 
ing for  older  people  initiated  in  the  Housing 
Act  of  1959,  which  the  Republican  administra- 
tion has  sought  to  kill. 

Special  Services.  We  shall  take  Federal  ac- 
tion in  support  of  state  efforts  to  bring  stand- 
ards of  care  in  nursing  homes  and  other  insti- 


tutions for  the  aged  up  to  desirable  mini- 
mums. 

We  shall  support  demonstration  and  train- 
ing programs  to  translate  proven  research  in- 
to action  in  such  fields  as  health,  nutritional 
guidance,  home  care,  counseling,  recreational 
activity. 

Taken  together,  these  measures  will  affirm 
a new  charter  of  rights  for  the  older  citizens 
among  us — the  right  to  a life  of  usefulness, 
health,  dignity,  independence  and  participa- 
tion. 

Welfare 

Disability  Insurance.  We  shall  permit 
workers  who  are  totally  and  permanently  dis- 
abled to  retire  at  any  age,  removing  the  ar- 
bitrary requirement  that  the  worker  be  50 
years  of  age. 

We  shall  also  amend  the  law  so  that  after 
six  months  of  total  disability,  a worker  will 
be  eligible  for  disability  benefits,  with  restor- 
ative services  to  enable  the  worker  to  return 
to  work. 

Physically  Handicapped.  We  pledge  contin- 
ued support  of  legislation  for  the  rehabilita- 
tion of  physically  handicapped  persons  and 
improvement  of  employment  opportunities 
for  them. 

Public  Assistance.  Persons  in  need  who  are 
inadequately  protected  by  social  insurance 
are  cared  for  by  the  states  and  local  com- 
munities under  public  assistance  programs. 

The  federal  government,  which  now  shares 
the  cost  of  aid  to  some  of  these,  should  share 
in  all,  and  benefits  should  be  made  available 
without  regard  to  residence. 

Unemployment  Benefits.  We  will  establish 
uniform  minimum  standards  throughout  the 
nation  for  coverage,  duration,  and  amount  of 
unemployment  insurance  benefits. 

Equality  for  Women.  We  support  legisla- 
tion which  will  guarantee  to  women  equality 
of  rights  under  the  law,  including  equal  pay 
for  equal  work. 


168 


J.  M.  A.  ALABAMA 


THE  ASSOCIATION  FORUM 


Child  Welfare.  The  Child  Welfare  Program 
and  other  services  already  established  under 
the  Social  Security  Act  should  be  expanded. 
Federal  leadership  is  required  in  the  nation- 
wide campaign  to  prevent  and  control  juve- 
nile delinquency. 

Intergroup  Relations.  We  propose  a Federal 
bureau  of  intergroup  relations  to  help  solve 
problems  of  discrimination  in  housing,  educa- 
tion, employment  and  community  opportuni- 
ties in  general.  The  bureau  would  assist  in 
the  solution  of  problems  arising  from  the  re- 
settlement of  immigrants  and  migrants  with- 
in our  own  country,  and  in  resolving  reli- 
gious, social  and  other  tensions  where  they 
arise. 


Education 

8.  “The  right  to  a good  education.” 

America's  young  people  are  our  greatest  re- 
sources for  the  future.  Each  of  them  deserves 
the  education  which  will  best  develop  his 
potentialities. 

We  shall  act  at  once  to  help  in  building  the 
classrooms  and  employing  the  teachers  that 
are  essential  if  the  right  to  a good  education 
is  to  have  genuine  meaning  for  all  the  youth 
of  America  in  the  decade  ahead. 

As  a national  investment  in  our  future  we 
propose  a program  of  loans  and  scholarship 
grants  to  assure  that  qualified  young  Ameri- 
cans will  have  full  opportunity  for  higher  ed- 
ucation, at  the  institutions  of  their  choice,  re- 
gardless of  the  income  of  their  parents. 

The  new  Democratic  administration  will 
end  eight  years  of  official  neglect  of  our  edu- 
cational system. 

America’s  education  faces  a financial  crisis. 
The  tremendous  increase  in  the  number  of 
children  of  school  and  college  age  has  far  out- 
run the  available  supply  of  educational  facili- 
ties and  qualified  teachers.  The  classroom 
shortage  alone  is  interfering  with  the  educa- 
tion of  10  million  students. 

America’s  teachers,  parents  and  school  ad- 
ministrators have  striven  courageously  to 


keep  up  with  the  increased  challenge  of  edu- 
cation. 

So  have  states  and  local  communities.  Edu- 
cation absorbs  two-fifths  of  all  their  revenue. 
With  limited  resources,  private  educational 
institutions  have  shouldered  their  share  of  the 
burden. 

Only  the  federal  government  is  not  doing 
its  part.  For  eight  years,  measures  for  the 
relief  of  the  educational  crisis  have  been  held 
up  by  the  cynical  maneuvers  of  the  Republi- 
can Party  in  Congress  and  the  White  House. 

We  believe  that  America  can  meet  its  edu- 
cational obligations  only  with  generous  fed- 
eral financial  support,  within  the  traditional 
framework  of  local  control.  The  assistance 
will  take  the  form  of  federal  grants  to  states 
for  educational  purposes  they  deem  most 
pressing,  including  classroom  construction 
and  teachers’  salaries.  It  will  include  aid  for 
the  construction  of  academic  facilities  as  well 
as  dormitories  at  colleges  and  universities. 

We  pledge  further  federal  support  for  all 
phases  of  vocational  education  for  youth  and 
adults;  for  libraries  and  adult  education;  for 
realizing  the  potential  of  educational  televi- 
sion; and  for  exchange  of  students  and  teach- 
ers with  other  nations. 

As  part  of  a broader  concern  for  young  peo- 
ple we  recommend  establishment  of  a Youth 
Conservation  Corps,  to  give  underprivileged 
young  people  a rewarding  experience  in  a 
healthful  environment. 

^ ^ ^ 

The  pledges  contained  in  this  Economic 
Bill  of  Rights  point  the  way  to  a better  life 
for  every  family  in  America. 

They  are  the  means  to  a goal  that  is  now 
within  our  reach — the  final  eradication  in 
America  of  the  age-old  evil  of  poverty. 

Yet  there  are  other  pressing  needs  on  our 
national  agenda. 


SEPTEMBER  I960— VOL.  30.  NO.  3 


169 


THE  ASSOCIATION  FORUM 


Natural  Resources 

A thin  laye.'  of  earth,  a few  inches  of  rain, 
and  a blanket  of  air  makes  human  life  pos- 
sible on  our  planet. 

Sound  public  policy  must  assure  that  these 
essential  resources  will  be  available  to  pro- 
vide the  good  life  for  our  children  and  future 
generations. 

Water,  timber  and  grazing  lands,  recrea- 
tional areas  in  our  parks,  shores,  forests  and 
wildernesses,  energy,  minerals,  even  pure  air 
— all  are  feeling  the  press  of  enormously  in- 
creased demands  of  a rapidly  growing  popu- 
lation. 

Natural  resources  are  the  birthright  of  all 
the  people. 

The  new  Democratic  administration,  with 
the  vision  that  built  a TVA  and  a Grand  Cou- 
lee, will  develop  and  conserve  that  heritage 
for  the  use  of  this  and  future  generations. 
We  will  reverse  Republican  policies  under 
which  America’s  resources  have  been  wasted, 
depleted,  underdeveloped,  and  recklessly  giv- 
en away. 

We  favor  the  best  use  of  our  natural  re- 
sources, which  generally  means  adoption  of 
the  multiple-purpose  principle  to  achieve  full 
development  for  all  the  many  functions  they 
can  serve. 

Water  and  Soil.  An  abundant  supply  of 
pure  water  is  essential  to  our  economy.  This 
is  a national  problem. 

Water  must  serve  domestic,  industrial  and 
irrigation  needs  and  inland  navigation.  It 
must  provide  habitat  for  fish  and  wildlife, 
supply  the  base  for  much  outdoor  recreation, 
and  generate  electricity.  Water  must  also  be 
controlled  to  prevent  floods,  pollution,  salini- 
ty and  silt. 

The  new  Democratic  administration  will 
develop  a comprehensive  national  water  re- 
source policy.  In  cooperation  with  state  and 
local  governments,  and  interested  private 
groups,  a Democratic  administration  will  de- 
velop a balanced,  multiple-purpose  plan  for 
each  major  river  basin  to  be  revised  periodi- 
cally to  meet  changing  needs.  We  will  erase 

I 70 


the  Republican  slogan  of  “no  new  starts”  and 
will  begin  again  to  build  multiple-purpose 
dams,  hydro-electric  facilities,  flood  control 
works,  navigation  facilities,  and  reclamation 
projects  to  meet  mounting  and  urgent  needs. 

We  will  renew  the  drive  to  protect  every 
acre  of  farm  land  under  a soil  and  water  con- 
servation plan  and  speed  up  the  small  water- 
shed program. 

We  will  support  and  intensify  the  research 
effort  to  find  an  economical  way  to  convert 
salt  and  brackish  water.  The  Republicans  dis- 
couraged this  research,  which  holds  untold 
possibilities  for  the  whole  world. 

Water  and  Air  Pollution.  America  can  no 
longer  take  pure  water  and  air  for  granted. 
Polluted  rivers  carry  their  dangers  to  every- 
one living  along  their  courses;  impure  air  does 
not  respect  boundaries. 

Federal  action  is  needed  in  planning,  coor- 
dinating and  helping  to  finance  pollution 
control.  The  states  and  local  communities 
cannot  go  it  alone.  Yet  President  Eisenhower 
vetoed  a Democratic  bill  to  give  them  more 
financial  help  in  building  sewage  treatment 
plants. 

A Democratic  President  will  sign  such  a 
bill. 

Democrats  will  step  up  research  on  pollu- 
tion control,  giving  special  attention  to: 

(1)  the  rapidly  growing  problem  of  air 
pollution  from  industrial  plants,  automobile 
exhausts,  and  other  sources,  and 

(2)  disposal  of  chemical  and  radioactive 
wastes,  some  of  which  are  now  being  dumped 
off  our  coasts  without  adequate  knowledge 
of  the  potential  consequences. 

Outdoor  Recreation.  As  population  grows 
and  the  work  week  shortens  and  transporta- 
tion becomes  easier  and  speedier,  the  need 
for  outdoor  recreation  facilities  mounts. 

We  must  act  quickly  to  retain  public  access 
to  the  oceans,  gulfs,  rivers,  streams,  lakes,  and 
reservoirs,  and  their  shorelines,  and  to  re- 
serve adequate  camping  and  recreational 
areas  while  there  is  yet  time.  Areas  near 
major  population  centers  are  particularly 
needed. 


J.  M.  A.  ALABAMA 


THE  ASSOCIATION  FORUM 


The  new  Democratic  administration  will 
work  to  improve  and  extend  recreation  oppor- 
tunities in  national  parks  and  monuments; 
forests;  river  development  projects;  and  near 
metropolitan  areas.  Emphasis  will  be  on  at- 
tractive, low-cost  facilities  for  all  the  people 
and  on  preventing  undue  commercialization. 

The  National  Park  System  is  still  incom- 
plete; in  particular,  the  few  remaining  suit- 
able shorelines  must  be  included  in  it.  A Na- 
tional Wilderness  System  should  be  created 
for  areas  already  set  aside  as  wildernesses. 
The  system  should  be  extended  but  only  after 
careful  consideration  by  the  Congress  of  the 
value  of  areas  for  competing  uses. 

Recreational  needs  of  the  surrounding  area 
should  be  given  important  consideration  in 
disposing  of  federally  owned  lands. 

We  will  protect  fish  and  game  habitats  from 
commercial  exploitation  and  require  military 
installations  to  conform  to  sound  conservation 
practices. 

Energy.  The  Republican  administration 
would  turn  the  clock  back  to  the  days  before 
the  New  Deal,  in  an  effort  to  divert  the  bene- 
fits of  the  great  natural  energy  resources 
from  all  the  people  to  a favored  few.  It  has 
followed  for  many  years  a “no  new  starts” 
policy. 

It  has  stalled  atomic  energy  development; 
it  has  sought  to  cripple  rural  electrification. 

It  has  closed  the  pilot  plant  on  getting  oil 
from  shale. 

It  has  harassed  and  hampered  the  TVA. 

We  reject  this  philosophy  and  these  policies. 
The  people  are  entitled  to  use  profitably  what 
they  already  own. 

The  Democratic  administration  instead  will 
foster  the  development  of  efficient  regional 
giant  power  systems  from  all  sources,  includ- 
ing water,  tidal,  and  nuclear,  to  supply  low- 
cost  electricity  to  all  retail  electric  systems, 
public,  private,  and  cooperative. 

The  Democratic  administration  will  con- 
tinue to  develop  “yardsticks”  for  measuring 
the  rates  of  private  utility  systems.  This 
means  meeting  the  needs  of  rural  electric  co- 


operatives for  low-interest  loans  for  distribu- 
tion, transmission  and  generation  facilities; 
federal  transmission  facilities,  where  appro- 
priate, to  provide  efficient  low-cost  power 
supply;  and  strict  enforcement  of  the  public- 
preference  clause  in  power  marketing. 

The  Democratic  administration  will  sup- 
port continued  study  and  research  on  energy 
fuel  resources,  including  new  sources  in  wind 
and  sun.  It  will  push  forward  with  the 
Passamaquoddy  tidal  power  project  with  its 
great  promise  of  cheaper  power  and  expanded 
prosperity  for  the  people  of  New  England. 

We  support  the  establishment  of  a national 
fuels  policy. 

The  $15  billion  national  investment  in 
atomic  energy  should  be  protected  as  a part 
of  the  public  domain. 

Federal  Lands  and  Forests.  The  record  of 
the  Republican  administration  in  handling 
the  public  domain  is  one  of  complete  lethargy. 
It  has  failed  to  secure  the  fullest  present 
benefits.  In  some  cases,  it  has  given  away 
priceless  resources  for  plunder  by  private 
corporations,  as  in  the  A1  Sarena  mining  inci- 
dent and  the  secret  leasing  of  game  refuges  to 
favored  oil  interests. 

The  new  Democratic  administration  will 
develop  balanced  land  and  forest  policies 
suited  to  the  needs  of  a growing  America. 

This  means  intensive  forest  management  on 
a multiple  use  and  sustained  yield  basis,  re- 
forestation of  burnt-over  lands,  building  pub- 
lic access  roads,  range  reseeding  and  improve- 
ment, intensive  work  in  watershed  manage- 
ment, concern  for  small  business  operations, 
and  insuring  free  public  access  to  public  lands 
for  recreational  uses. 

Minerals.  America  uses  half  the  minerals 
produced  in  the  entire  free  world.  Yet  our 
mining  industry  is  in  what  may  be  the  initial 
phase  of  a serious  long-term  depression. 
Sound  policy  requires  that  we  strengthen  the 
domestic  mining  industry  without  interfering 
with  adequate  supplies  of  needed  materials  at 
reasonable  costs. 


SEPTEMBER  I960— VOL.  30,  NO.  3 


171 


THE  ASSOCIATION  FORUM 


We  pledge  immediate  efforts  toward  the 
establishment  of  a realistic  long  range  min- 
erals policy. 

The  new  Democratic  administration  will 
begin  intensive  research  on  scientific  pros- 
pecting for  mineral  deposits. 

We  will  speed  up  the  geologic  mapping  of 
the  country,  with  emphasis  on  Alaska. 

We  will  resume  research  and  development 
work  on  use  of  low-grade  mineral  reserves, 
especially  oil  shale,  lignites,  iron  ore  taconite, 
and  radioactive  minerals.  These  efforts  have 
been  halted  or  cut  back  by  the  Republican 
administration. 

The  Democratic  Party  favors  a study  of  the 
problem  of  non-uniform  seaward  boundaries 
of  the  coastal  states. 

Government  Machinery  for  Managing  Re- 
sources. Long-range  programming  of  the  na- 
tion’s resource  development  is  essential.  We 
favor  creation  of  a council  of  advisors  on  re- 
sources and  conservation,  which  will  evalu- 
ate and  report  annually  upon  our  resource 
needs  and  progress. 

We  shall  put  budgeting  for  resources  on  a 
business-like  basis,  distinguishing  between 
operating  expense  and  capital  investment,  so 
that  the  country  can  have  an  accurate  picture 
of  the  costs  and  returns.  We  propose  the  in- 
cremental method  in  determining  the  eco- 
nomic justification  of  our  river  basin  pro- 
grams. Charges  for  commercial  use  of  public 
lands  will  be  brought  into  line  with  benefits 
received. 


Cities  and  Their  Suburbs 

A new  Democratic  administration  will  ex- 
pand federal  programs  to  aid  urban  commu- 
nities to  clear  their  slums,  dispose  of  their 
sewage,  educate  their  children,  transport  sub- 
urban commuters  to  and  from  their  jobs,  and 
combat  juvenile  delinquency. 

We  will  give  the  city  dweller  a voice  at  the 
Cabinet  table  by  bringing  together  within  a 
single  department  programs  concerned  with 
urban  and  metropolitan  problems. 


The  United  States  is  now  predominantly  an 
urban  nation. 

The  efficiency,  comfort,  and  beauty  of  our 
cities  and  suburbs  influence  the  lives  of  all 
Americans. 

Local  governments  have  found  increasing 
difficulty  in  coping  with  such  fundamental 
public  problems  as  urban  renewal,  slum  clear- 
ance, water  supply,  mass  transportation,  rec- 
reation, health,  welfare,  education  and  metro- 
politan planning.  These  problems  are,  in 
many  cases,  interstate  and  regional  in  scope. 

Yet  the  Republican  administration  has 
turned  its  back  upon  urban  and  suburban 
America.  The  list  of  Republican  vetoes  in- 
cludes housing,  urban  renewal  and  slum 
clearance,  area  redevelopment,  public  works, 
airports  and  stream  pollution  control.  It  has 
proposed  severe  cut-backs  in  aid  for  hospital 
construction,  public  assistance,  vocational  ed- 
ucation, community  facilities  and  sewage  dis- 
posal. 

The  result  has  been  to  force  communities  to 
thrust  an  ever-greater  tax  load  upon  the  al- 
ready overburdened  property  taxpayer  and  to 
forego  needed  public  services. 

The  Democratic  Party  believes  that  state 
and  local  governments  are  strengthened — not 
weakened — by  financial  assistance  from  the 
federal  government.  We  will  extend  such  aid 
without  impairing  local  administration 
through  unnecessary  federal  interference  or 
redtape. 

We  propose  a ten-year  action  program  to 
restore  our  cities  and  provide  for  balanced 
suburban  development,  including  the  follow- 
ing; 

1.  The  elimination  of  slums  and  blight  and 
the  restoration  of  cities  and  depressed  areas 
within  the  next  ten  years. 

2.  Federal  aid  for  metropolitan  area  plan- 
ning and  community  facility  programs. 

3.  Federal  aid  for  comprehensive  metro- 
politan transportation  programs,  including 
bus  and  rail  mass  transit,  commuter  railroads 
as  well  as  highway  programs  and  construc- 
tion of  civil  airports. 


172 


J.  M.  A.  ALABAMA 


THE  ASSOCIATION  FORUM 


4.  Federal  aid  in  combatting  air  and  water 
pollution. 

5.  Expansion  of  park  systems  to  meet  the 
recreation  needs  of  our  growing  population. 

The  federal  government  must  recognize  the 
financial  burdens  placed  on  local  govern- 
ments, urban  and  rural  alike,  by  federal  in- 
stallations and  land  holdings. 


Transportation 

Over  the  past  seven  years,  we  have 
watched  the  steady  weakening  of  the  nation's 
transportation  system.  Railroads  are  in  dis- 
tress. Highways  are  congested.  Airports  and 
airways  lag  far  behind  the  needs  of  the  jet 
age. 

To  meet  this  challenge  we  will  establish  a 
national  transportation  policy,  designed  to  co- 
ordinate and  modernize  our  facilities  for 
transportation  by  road,  rail,  water,  and  air. 

Air.  The  jet  age  has  made  rapid  improve- 
ment in  air  safety  imperative.  Rather  than 
“an  orderly  withdrawal”  from  the  airport 
grant  programs  as  proposed  by  the  Republi- 
can administration,  we  pledge  to  expand  the 
program  to  accommodate  growing  air  traffic. 

Water.  Development  of  our  inland  water- 
ways, our  harbors,  and  Great  Lakes  commerce 
have  been  held  back  by  the  Republican  Presi- 
dent. 

We  pledge  the  improvement  of  our  rivers 
and  harbors  by  new  starts  and  adequate 
maintenance. 

A strong  and  efficient  American-flag  Mer- 
chant Marine  is  essential  to  peace-time  com- 
merce and  defense  emergencies.  Continued 
aid  for  ship  construction  and  operation  to  off- 
set cost  differentials  favoring  foreign  ship- 
ping is  essential  to  these  goals. 

Roads.  The  Republican  administration  has 
slowed  down,  stretched  out  and  greatly  in- 
creased the  costs  of  the  interstate  highway 
program. 

The  Democratic  Party  supports  the  high- 
way program  embodied  in  the  Acts  of  1956 


and  1958  and  the  principle  of  federal-state 
partnership  in  highway  construction. 

We  commend  the  Democratic  Congress  for 
establishing  a special  committee  which  has 
launched  an  extensive  investigation  of  this 
highway  program.  Continued  scrutiny  of  this 
multi-billion  dollar  highway  program  can 
prevent  waste,  inefficiency  and  graft  and 
maintain  the  public’s  confidence. 

Rail.  The  nation’s  railroads  are  in  particu- 
lar need  of  freedom  from  burdensome  regu- 
lation to  enable  them  to  compete  effectively 
with  other  forms  of  transportation.  We  also 
support  federal  assistance  in  meeting  certain 
capital  needs  particularly  for  urban  mass 
transportation. 


Science 

We  will  recognize  the  special  role  of  our 
federal  government  in  support  of  basic  and 
applied  research. 

Space.  The  Republican  administration  has 
remained  incredibly  blind  to  the  prospects  of 
space  exploration.  They  have  failed  to  pur- 
sue space  programs  with  a sense  of  urgency 
anywhere  near  equal  to  their  importance  to 
the  future  of  the  world. 

It  has  allowed  the  Communists  to  forge 
ahead  to  hit  the  moon  first,  and  to  launch  sub- 
stantially greater  payloads.  The  Republican 
program  is  a catch-all  of  assorted  projects 
with  no  clearly-defined,  long-range  plan  of 
research. 

The  new  Democratic  administration  will 
press  forward  with  our  national  space  pro- 
gram in  full  realization  of  the  importance  of 
space  accomplishments  to  our  national  securi- 
ty and  our  international  prestige.  We  shall 
reorganize  the  program  to  achieve  both  ef- 
ficiency and  speedy  execution.  We  shall  bring 
top  scientists  in  positions  of  responsibility. 
We  shall  undertake  long-term  basic  research 
in  space  science  and  propulsion. 

We  shall  initiate  negotiations  leading  to- 
ward the  international  regulation  of  space. 


SEPTEMBER  I960— VOL.  30,  NO.  3 


173 


THE  ASSOCIATION  FORUM 


Atomic  Energy.  The  United  States  became 
pre-eminent  in  the  development  of  atomic  en- 
ergy under  Democratic  administrations. 

The  Republican  administration,  despite  its 
glowing  promises  of  “Atoms  for  Peace,”  has 
permitted  the  gradual  deterioration  of  United 
States  leadership  in  atomic  development  both 
at  home  and  abroad. 

In  order  to  restore  United  States  leadership 
in  atomic  development,  the  new  Democratic 
Administration  will: 

1.  Restore  truly  non-partisan  and  vigorous 
administration  of  the  vital  atomic  energy  pro- 
gram; 

2.  Continue  the  development  of  the  various 
promising  experimental  and  prototype  atomic 
power  plants  which  show  promise,  and  pro- 
vide increasing  support  for  longer  range  proj- 
ects at  the  frontiers  of  atomic  energy  applica- 
tion; 

3.  Continue  to  preserve  and  support  na- 
tional laboratories  and  other  federal  atomic 
installations  as  the  foundation  of  technical 
progress  and  bulwark  of  national  defense; 

4.  Accelerate  the  Rover  nuclear  rocket 
project  and  auxiliary  power  facilities  so  as  to 
achieve  world  leadership  in  peaceful  outer 
space  exploration; 

5.  Give  reality  to  the  United  States’  inter- 
national atoms  for  peace  programs  and  to 
continue  and  expand  technological  assistance 
to  underdeveloped  countries; 

6.  Consider  measures  for  improved  organ- 
ization and  procedure  for  radiation  protection, 
and  reactor  safety,  including  strengthening 
the  role  of  the  Federal  Radiation  Council,  and 
the  separation  of  quasi-judicial  functions  in 
reactor  safety  regulations; 

7.  Provide  a balance  and  flexible  nuclear 
defense  capability,  including  the  augmenta- 
tion of  the  nuclear  submarine  fleet. 

Oceanography.  Oceanographic  research  is 
needed  to  advance  such  important  programs 
as  food  and  minerals  from  our  Great  Lakes 
and  the  sea.  The  present  Administration  has 
neglected  this  new  scientific  frontier. 


Government  Operations 

We  shall  reform  the  processes  of  govern- 
ment in  all  branches — executive,  legislative, 
and  judicial.  We  will  clean  out  corruption  and 
conflicts  of  interest,  and  improve  government 
services. 

The  Federal  Service.  Two  weeks  before  this 
platform  was  adopted,  the  difference  between 
the  Democratic  and  Republican  attitudes  to- 
ward government  employees  was  dramati- 
cally illustrated.  The  Democratic  Congress 
passed  a fully  justified  pay  increase  to  bring 
government  pay  scales  more  nearly  in  line 
with  those  of  private  industry. 

The  Republican  President  vetoed  the  pay 
raise. 

The  Democratic  Congress  decisively  over- 
rode the  veto. 

The  heavy  responsibilities  of  modern  gov- 
ernment require  a federal  service  character- 
ized by  devotion  to  duty,  honesty  of  purpose, 
and  highest  competence.  We  pledge  the  mod- 
ernization and  strengthening  of  our  civil  ser- 
vice system. 

We  shall  extend  and  improve  the  employ- 
ees’ appeals  system  and  improve  programs 
for  recognizing  the  outstanding  merits  of  in- 
dividual employees. 

Ethics  in  Government.  We  reject  totally  the 
concept  of  dual  or  triple  loyalty  on  the  part 
of  federal  officials  in  high  places. 

The  conflict-of-interest  statutes  should  be 
revised  and  strengthened  to  assure  the  federal 
service  of  maximum  security  against  unethi- 
cal practices  on  the  part  of  public  officials. 

The  Democratic  administration  will  estab- 
lish and  enforce  a Code  of  Ethics  to  maintain 
the  full  dignity  and  integrity  of  the  federal 
service  and  to  make  it  more  attractive  to  the 
ablest  men  and  women. 

Regulatory  Agencies.  The  Democratic  Par- 
ty promises  to  clean  up  the  federal  regulatory 
agencies.  The  acceptance  by  Republican  ap- 
pointees to  these  agencies  of  gifts,  hospitality, 
and  bribes  from  interests  under  their  jurisdic- 
tion has  been  a particularly  flagrant  abuse 
of  public  trust. 


174 


J.  M.  A.  ALABAMA 


THE  ASSOCIATION  FORUM 


We  shall  bring  all  contacts  with  commis- 
sioners into  the  open,  and  will  protect  them 
from  any  form  of  improper  pressure. 

We  shall  appoint  to  these  agencies  men  of 
ability  and  independent  judgment  who  under- 
stand that  their  function  is  to  regulate  these 
industries  in  the  public  interest. 

We  promise  a thorough  review  of  existing 
agency  practices,  with  an  eye  toward  speedier 
decisions,  and  a clearer  definition  of  what 
constitutes  the  public  interest. 

The  Democratic  Party  condemns  the  usur- 
pation by  the  Executive  of  the  powers  and 
functions  of  any  of  the  independent  agencies 
and  pledges  the  restoration  of  the  independ- 
ence of  such  agencies  and  the  protection  of 
their  integrity  of  action. 

The  Postal  Service.  The  Republican  policy 
has  been  to  treat  the  United  States  postal 
service  as  a liability  instead  of  a great  invest- 
ment in  national  enlightenment,  social  effici- 
ency and  economic  betterment. 

Constant  curtailment  of  service  has  incon- 
venienced every  citizen. 

A program  must  be  undertaken  to  establish 
the  Post  Office  Department  as  a model  of  ef- 
ficiency and  service.  We  pledge  ourselves  to: 

1.  Restore  the  principle  that  the  postal  ser- 
vice is  a public  service. 

2.  Separate  the  public  service  costs  from 
those  to  be  borne  by  the  users  of  the  mails. 

3.  Continue  steady  improvement  in  work- 
ing conditions  and  wage  scales,  reflecting  in- 
creasing productivity. 

4.  Establish  a long-range  program  for  re- 
search and  capital  improvements  compatible 
with  the  highest  standards  of  business  effici- 
ency. 

Law  Enforcement.  In  recent  years,  we  have 
been  faced  with  a shocking  increase  in  crimes 
of  all  kinds.  Organized  criminals  have  even 
infiltrated  into  legitimate  business  enter- 
prises and  labor  unions. 

The  Republican  administration,  and  partic- 
ularly the  Attorney  General’s  office,  has  fail- 
ed lamentably  to  deal  with  this  problem  de- 

SEPTEMBER  I960— VOL.  30,  NO.  3 


spite  the  growing  nower  of  the  underworld. 
The  new  Democratic  administration  will  take 
vigorous  corrective  action. 

Freedom  of  Information.  We  reject  the  Re- 
publican contention  that  the  workings  of  gov- 
ernment are  the  special  private  preserve  of 
the  Executive. 

The  massive  wall  of  secrecy  erected  be- 
tween the  Executive  branch  and  the  Congress 
as  well  as  the  citizen  must  be  torn  down.  In- 
formation must  flow  freely,  save  in  those 
areas  in  which  the  national  security  is  in- 
volved. 

Clean  Elections.  The  Democratic  Party  fa- 
vors realistic  and  effective  limitations  on  con- 
tributions and  expenditures  and  full  disclos- 
ure of  campaign  financing  in  federal  elec- 
tions. 

We  further  propose  a tax  credit  to  encour- 
age small  contributions  to  political  parties. 

The  Democratic  Party  affirms  that  every 
candidate  for  public  office  has  a moral  obliga- 
tion to  observe  and  uphold  traditional  Ameri- 
can principles  of  decency,  honesty  and  fair 
play  in  his  campaign  for  election. 

We  deplore  efforts  to  divide  the  United 
States  into  regional,  religious  and  ethnic 
groups. 

We  denounce  and  repudiate  campaign  tac- 
tics that  substitute  smear  and  slander,  bigotry 
and  false  accusations  of  bigotry  for  truth  and 
reasoned  argument. 

District  of  Columbia.  The  Capital  city  of 
our  nation  should  be  a symbol  of  democracy 
to  people  throughout  the  world.  The  Demo- 
cratic Party  reaffirms  its  long-standing  sup- 
port for  home  rule  for  the  District  of  Colum- 
bia, and  pledges  to  enact  legislation  permit- 
ting voters  of  the  District  to  elect  their  own 
local  government. 

We  urge  the  legislatures  of  the  fifty  states 
to  ratify  the  23rd  Amendment,  passed  by  the 
Democratic  Congress,  to  give  District  citizens 
the  right  to  participate  in  Presidential  elec- 
tions. 

We  also  support  a Constitutional  Amend- 
ment giving  the  District  voting  representation 
in  Congress. 

I 75 


THE  ASSOCIATION  FORUM 


Virgin  Islands.  We  believe  that  the  voters 
of  the  Virgin  Islands  should  have  the  right  to 
elect  their  own  Governor,  to  have  a delegate 
in  the  Congress  of  the  United  States  and  to 
have  the  right  to  vote  in  national  elections  for 
a President  and  Vice  President  of  the  United 
States. 

Puerto  Rico.  The  social,  economic,  and  po- 
litical progress  of  the  Commonwealth  of 
Puerto  Rico  is  a testimonial  to  the  sound  en- 
abling legislation,  and  the  sincerity  and  un- 
derstanding with  which  the  people  of  the 
United  States  and  Puerto  Rico  are  meeting 
their  joint  problems. 

The  Democratic  Party,  under  whose  ad- 
ministration the  Commonwealth  status  was 
established,  is  entitled  to  great  credit  for  pro- 
viding the  opportunity  which  the  people  of 
Puerto  Rico  have  used  so  successfully. 

Puerto  Rico  has  become  a show-place  of 
world-wide  interest,  a tribute  to  the  benefits 
of  the  principles  of  self-determination.  Furth- 
er benefits  for  Puerto  Rico  under  these  prin- 
ciples are  certain  to  follow. 

Congressional  Procedures 

In  order  that  the  will  of  the  American  peo- 
ple may  be  expressed  upon  all  legislative 
proposals,  we  urge  that  action  be  taken  at  the 
beginning  of  the  87th  Congress  to  improve 
Congressional  procedures  so  that  majority 
rule  prevails  and  decisions  can  be  made  after 
reasonable  debate  without  being  blocked  by 
a minority  in  either  House. 

The  rules  of  the  House  of  Representatives 
should  be  amended  so  as  to  make  sure  that 
bills  reported  by  legislative  committees 
should  reach  the  floor  for  consideration  with- 
out undue  delay. 

Consumers 

In  an  age  of  mass  production,  distribution, 
and  advertising,  consumers  require  effective 
government  representation  and  protection. 

The  Republican  administration  has  allowed 
the  Food  and  Drug  Administration  to  be 


weakened.  Recent  Senate  hearings  on  the 
drugs  industry  have  revealed  how  flagrant 
profiteering  can  be  when  essential  facts  on 
costs,  prices,  and  profits  are  hidden  from 
scrutiny.  The  new  Democratic  Administra- 
tion will  provide  the  money  and  the  authority 
to  strengthen  this  agency  for  its  task. 

We  propose  a consumer  counsel,  backed  by 
a suitable  staff,  to  speak  for  consumers  in  the 
formulation  of  government  policies  and  rep- 
resent consumers  in  administrative  proceed- 
ings. 

The  consumer  also  has  a right  to  know  the 
cost  of  credit  when  he  borrows  money.  We 
shall  enact  federal  legislation  requiring  the 
vendors  of  credit  to  provide  a statement  of 
specific  credit  charges  and  what  these  charges 
cost  in  terms  of  true  annual  interest. 

Veterans  Affairs 

We  adhere  to  the  American  tradition  found 
in  the  Plymouth  Colony  in  New  England  in 
1636,  which  holds  that; 

“ . . . any  soldier  injured  in  defense  of 

the  colony  shall  be  maintained  com- 
petently by  the  colony  for  the  remainder 

of  his  life.” 

We  pledge  adequate  compensation  for  those 
with  service  connected  disabilities  and  for  the 
survivors  of  those  who  died  in  service  or  from 
service  connected  disabilities.  We  pledge  pen- 
sions adequate  for  a full  and  dignified  life  for 
disabled  and  distressed  veterans  and  for 
needy  survivors  of  deceased  veterans. 

Veterans  of  World  War  I,  whose  federal 
benefits  have  not  matched  those  of  veterans 
of  subsequent  service,  will  receive  the  special 
attention  of  the  Democratic  Party  looking 
toward  equitable  adjustments. 

We  endorse  expanded  programs  of  voca- 
tional rehabilitation  for  disabled  veterans, 
and  education  for  orphans  of  servicemen. 

The  quality  of  medical  care  furnished  to  the 
disabled  veterans  has  deteriorated  under  the 
Republican  Administration.  We  shall  work 
for  an  increased  availability  of  facilities  for 
all  veterans  in  need  and  we  will  move  with 


176 


J.  M.  A.  ALABAMA 


THE  ASSOCIATION  FORUM 


particular  urgency  to  fulfill  the  need  for  ex- 
panded domiciliary  and  nursing  home  facili- 
ties. 

We  shall  continue  the  veterans  home  loan 
guarantee  and  direct  loan  programs  and  edu- 
cational benefits  patterned  after  the  G.I.  Bill 
of  Rights. 

American  Indians 

We  recognize  the  unique  legal  and  moral 
responsibility  of  the  federal  government  for 
Indians  and  in  restitution  to  the  Indians  for 
the  injustice  that  has  sometimes  been  done 
them.  We  therefore  pledge  prompt  adoption 
of  a program  to  assist  Indian  tribes  in  the  full 
development  of  their  human  and  natural  re- 
sources and  to  advance  the  health,  education, 
and  economic  well-being  of  Indian  citizens 
while  preserving  their  cultural  heritage. 

Free  consent  of  the  Indian  tribes  concerned 
shall  be  required  before  the  federal  govern- 
ment makes  any  change  in  any  federal  Indian 
treaty  or  other  contractual  relationship. 

The  new  Democratic  Administration  will 
bring  competent,  sympathetic,  and  dedicated 
leadership  to  the  administration  of  Indian  af- 
fairs which  will  end  practices  that  have 
eroded  Indian  rights  and  resources,  reduced 
the  Indians’  land  base  and  repudiated  federal 
responsibility.  Indian  claims  against  the 
United  States  can  and  will  be  settled  prompt- 
ly, whether  by  negotiation  or  other  means, 
in  the  best  interests  of  both  parties. 


The  Arts 

The  arts  flourish  where  there  is  freedom 
and  where  individual  initiative  and  imagina- 
tion are  encouraged.  We  enjoy  the  blessings 
of  such  an  atmosphere. 

The  nation  should  begin  to  evaluate  the 
possibilities  for  encouraging  and  expanding 
participation  in  and  appreciation  of  our  cul- 
tural life. 

We  propose  a federal  advisory  agency  to 
assist  in  the  evaluation,  development,  and  ex- 


pansion of  cultural  resources  of  the  United 
States.  We  shall  support  legislation  needed  to 
provide  incentives  for  those  endowed  with  ex- 
traordinary talent  as  a worthy  supplement  to 
existing  scholarship  programs. 

Civil  Liberties 

Today  with  democratic  values  threatened 
by  Communist  tyranny,  we  reaffirm  our  dedi- 
cation to  the  Bill  of  Rights.  Freedom  and  civil 
liberties,  far  from  being  incompatible  with 
security,  are  vital  to  our  national  strength. 
Unfortunately,  those  high  in  the  Republican 
administration  have  all  too  often  sullied  the 
name  and  honor  of  loyal  and  faithful  Ameri- 
can citizens  in  and  out  of  government. 

The  Democratic  Party  will  strive  to  im- 
prove Congressional  investigating  and  hear- 
ing procedures.  We  shall  abolish  useless  dis- 
claimer affidavits  such  as  those  for  student 
educational  loans.  We  shall  provide  a full 
and  fair  hearing,  including  confrontation  of 
the  accuser,  to  any  person  whose  public  or 
private  employment  or  reputation  is  jeopard- 
ized by  a loyalty  or  security  proceeding. 

Protection  of  rights  of  American  citizens  to 
travel,  to  pursue  lawful  trade  and  to  engage 
in  other  lawful  activities  abroad  without  dis- 
tinction as  to  race  or  religion  is  a cardinal 
function  of  the  national  sovereignty. 

We  will  oppose  any  international  agree- 
ment or  treaty  which  by  its  terms  or  prac- 
tices differentiates  among  American  citizens 
on  grounds  of  race  or  religion. 

^ ^ 

The  list  of  unfinished  business  for  America 
is  long.  The  accumulated  neglect  of  nearly  a 
decade  cannot  be  wiped  out  overnight.  Many 
of  the  objectives  which  we  seek  will  require 
our  best  efforts  over  a period  of  years. 

Although  the  task  is  far-reaching,  we  will 
tackle  it  with  vigor  and  confidence.  We  will 
substitute  planning  for  confusion,  purpose  for 
indifference,  direction  for  drift  and  apathy. 

We  will  organize  the  policy-making  ma- 
chinery of  the  executive  branch  to  provide 


SEPTEMBER  I960— VOL.  30,  NO.  3 


177 


THE  ASSOCIATION  FORUM 


vigor  and  leadership  in  establishing  our  na- 
tional goals,  and  achieving  them. 

The  new  Democratic  President  will  sign, 
not  veto,  the  efforts  of  a Democratic  Congress 
to  create  more  jobs,  to  build  more  homes,  to 
save  family  farms,  to  clean  up  polluted 
streams  and  rivers,  to  help  depressed  areas, 
and  to  provide  full  employment  for  our  peo- 
ple. 


Fiscal  Responsibility 

We  vigorously  reject  the  notion  that  Amer- 
ica, with  a half-trillion-dollar  gross  national 
product,  and  nearly  half  of  the  world's  indus- 
trial resources,  cannot  afford  to  meet  the 
needs  of  her  people  at  home  and  in  our  world 
relationships. 

We  believe,  moreover,  that  except  in  pe- 
riods of  recessions  or  national  emergency, 
these  needs  can  be  met  with  a balanced  bud- 
get, with  no  increase  in  present  tax  rates, 
and  with  some  surplus  for  the  gradual  reduc- 
tion of  our  national  debt. 

To  assure  such  a balance  we  shall  pursue  a 
four-point  program  of  fiscal  responsibility. 

First,  we  shall  end  the  gross  waste  in  fed- 
eral expenditures  which  needlessly  raises  the 
budgets  of  many  goyernment  agencies. 

The  most  conspicuous  unnecessary  item  is, 
of  course,  the  excessive  cost  of  interest  on  the 
national  debt.  Courageous  action  to  end  du- 
plication and  competition  among  the  armed 
services  will  achieve  large  savings.  The  cost 
of  the  agricultural  program  can  be  reduced 
while  at  the  same  time  restoring  prosperity 
to  the  nation’s  farmers. 

Second,  we  shall  collect  the  billions  in  tax- 
es which  are  owed  to  the  federal  government 
but  not  now  collected. 

The  Internal  Revenue  Service  is  still  suffer- 
ing from  the  cuts  inflicted  upon  its  enforce- 
ment staff  by  the  Republican  administration 
and  the  Republican  Congress  in  1953. 

The  Administration’s  own  Commissioner  of 
Internal  Revenue  has  testified  that  billions  of 
dollars  in  revenue  are  lost  each  year  because 


the  Service  does  not  have  sufficient  agents  to 
follow  up  on  tax  evasion. 

We  will  add  enforcement  personnel,  and  de- 
velop new  techniques  of  enforcement,  to  col- 
lect tax  revenue  which  is  now  being  lost 
through  evasion. 

Third,  we  shall  close  the  loopholes  in  the 
tax  laws  by  which  certain  privileged  groups 
legally  escape  their  fair  share  of  taxation. 

Among  the  more  conspicuous  loopholes  are 
depletion  allowances  which  are  inequitable, 
special  consideration  for  recipients  of  divi- 
dend income,  and  deductions  for  extravagant 
“business  expenses’’  which  have  reached 
scandalous  proportions. 

Tax  reform  can  raise  additional  revenue 
and  at  the  same  time  increase  legitimate  in- 
centives for  growth,  and  make  it  possible  to 
ease  the  burden  on  the  general  taxpayer  who 
now  pays  an  unfair  share  of  taxes  because  of 
special  favors  to  the  few. 

Fourth,  we  shall  bring  in  added  federal  tax 
revenues  by  expanding  the  economy  itself. 
Each  dollar  of  additional  production  puts  an 
additional  18  cents  in  tax  revenue  in  the  na- 
tional treasury.  A 5 per  cent  growth  rate, 
therefore,  will  yield  over  $40  billion  in  added 
revenue  in  four  years  at  present  tax  rates. 

By  these  four  methods  we  can  sharply  in- 
crease the  government  funds  available  for 
needed  services,  for  correction  of  tax  inequi- 
ties, and  for  debt  or  tax  reduction. 

Much  of  the  challenge  of  the  1960's,  how- 
ever, remains  unforeseen  and  unforeseeable. 

If.  therefore,  the  unfolding  demands  of  the 
new  decade  at  home  or  abroad  should  impose 
clear  national  responsibilities  that  cannot  be 
fulfilled  without  higher  taxes,  we  will  not  al- 
low political  disadvantage  to  deter  us  from 
doing  what  is  required. 

As  we  proceed  with  the  urgent  task  of  re- 
storing America's  productivity,  confidence, 
and  power,  we  will  never  forget  that  our  na- 
tional interest  is  more  than  the  sum  total  of 
all  the  group  interests  in  America. 

When  group  interests  conflict  with  the  na- 
tional interest,  it  will  be  the  national  interest 
which  we  serve. 


178 


J.  M.  A.  ALABAMA 


THE  ASSOCIATION  FORUM 


IV 

On  its  values  and  goals  the  quality  of  Amer- 
ican life  depends.  Here  above  all  our  national 
interest  and  our  devotion  to  the  Rights  of 
Man  coincide. 

Democratic  administrations  under  Wilson. 
Roosevelt,  and  Truman  led  the  way  in  press- 
ing for  economic  justice  for  all  Americans. 

But  man  does  not  live  by  bread  alone.  A 
new  Democratic  administration,  like  its  pred- 
ecessors, will  once  again  look  beyond  materi- 
al goals  to  the  spiritual  meaning  of  American 
society. 

We  have  drifted  into  a national  mood  that 
accepts  payola  and  quiz  scandals,  tax  evasion 
and  false  expense  accounts,  soaring  crime 
rates,  influence-peddling  in  high  government 
circles,  and  the  exploitation  of  sadistic  vio- 
lence as  popular  entertainment. 

For  eight  long  critical  years  our  present  na- 
tional leadership  has  made  no  effective  effort 
to  reverse  this  mood. 

The  new  Democratic  administration  will 
help  create  a sense  of  national  purpose  and 
higher  standards  of  public  behavior. 


Civil  Rights 

We  shall  also  seek  to  create  an  affirmative 
new  atmosphere  in  which  to  deal  with  racial 
divisions  and  inequalities  which  threaten 
both  the  integrity  of  our  democratic  faith  and 
the  proposition  on  which  our  nation  was 
founded — that  all  men  are  created  equal.  It 
is  our  faith  in  human  dignity  that  distin- 
guishes our  open  free  society  from  the  closed 
totalitarian  society  of  the  Communists. 

The  Constitution  of  the  United  States  re- 
jects the  notion  that  the  Rights  of  Man  means 
the  rights  of  some  men  only.  We  reject  it  too. 

The  right  to  vote  is  the  first  principle  of 
self-government.  The  Constitution  also  guar- 
antees to  all  Americans  the  equal  protection 
of  the  laws. 

It  is  the  duty  of  the  Congress  to  enact  the 
laws  necessary  and  proper  to  protect  and  pro- 


mote these  Constitutional  rights.  The  Su- 
preme Court  has  the  power  to  interpret  these 
rights  and  the  laws  thus  enacted. 

It  is  the  duty  of  the  President  to  see  that 
these  rights  are  respected  and  the  Constitu- 
tion and  laws  as  interpreted  by  the  Supreme 
Court  are  faithfully  executed. 

What  is  now  required  is  effective  moral 
and  political  leadership  by  the  whole  execu- 
tive branch  of  our  government  to  make  equal 
opportunity  a living  reality  for  all  Americans. 

As  the  party  of  Jefferson,  we  shall  provide 
that  leadership. 

In  every  city  and  state  in  greater  or  lesser 
degree  there  is  discrimination  based  on  color, 
race,  religion,  or  national  origin. 

If  discrimination  in  voting,  education,  the 
administration  of  justice  or  segregated  lunch- 
counters  are  the  issues  in  one  area,  discrimi- 
nation in  housing  and  employment  may  be 
pressing  questions  elsewhere. 

The  peaceful  demonstrations  for  first-class 
citizenship  which  have  recently  taken  place 
in  many  parts  of  this  country  are  a signal  to 
all  of  us  to  make  good  at  long  last  the  guar- 
antees of  our  Constitution. 

The  time  has  come  to  assure  equal  access 
for  all  Americans  to  all  areas  of  community 
life,  including  voting  booths,  schoolrooms, 
jobs,  housing,  and  public  facilities. 

The  Democratic  administration  which 
takes  office  next  January  will  therefore  use 
the  full  powers  provided  in  the  Civil  Rights 
Act  of  1957  and  1960  to  secure  for  all  Ameri- 
cans the  right  to  vote. 

If  these  powers,  vigorously  invoked  by  a 
new  Attorney  General  and  backed  by  a strong 
and  imaginative  Democratic  President,  prove 
inadequate,  further  powers  will  be  sought. 

We  will  support  whatever  action  is  neces- 
sary to  eliminate  literacy  tests  and  the  pay- 
ment of  poll  taxes  as  requirements  for  voting. 

A new  Democratic  administration  will  also 
use  its  full  powers — legal  and  moral — to  en- 
sure the  beginning  of  good  faith  compliance 
with  the  Constitutional  requirement  that  ra- 
cial discrimination  be  ended  in  public  educa- 
tion. 


SEPTEMBER  I960— VOL.  30,  NO.  3 


179 


THE  ASSOCIATION  FORUM 


We  believe  that  every  school  district  af- 
fected by  the  Supreme  Court's  school  deseg- 
regation decision  should  submit  a plan  pro- 
viding for  at  least  first-step  compliance  by 
1963,  the  100th  anniversary  of  the  Emancipa- 
tion Proclamation. 

To  facilitate  compliance,  technical  and  fi- 
nancial assistance  should  be  given  to  school 
districts  facing  special  problems  of  transition. 

For  this  and  for  the  protection  of  all  other 
Constitutional  rights  of  Americans,  the  At- 
torney General  should  be  empowered  and 
directed  to  file  civil  injunction  suits  in  federal 
courts  to  prevent  the  denial  of  any  civil  rights 
on  grounds  of  race,  creed,  or  color. 

The  new  Democratic  administration  will 
support  Federal  legislation  establishing  a 
Fair  Employment  Practices  Commission  ef- 
fectively to  secure  for  everyone  the  right  to 
equal  opportunity  for  employment. 

In  1949  the  President's  Committee  on  Civil 
Rights  recommended  a permanent  Commis- 
sion on  Civil  Rights.  The  new  Democratic 
administration  will  broaden  the  scope  and 
strengthen  the  powers  of  the  present  commis- 
sion and  make  it  permanent. 

Its  functions  will  be  to  provide  assistance 
to  communities,  industries,  or  individuals  in 
the  implementation  of  Constitutional  rights 
in  education,  housing,  employment,  transpor- 
tation, and  the  administration  of  justice. 

In  addition,  the  Democratic  administration 
will  use  its  full  executive  powers  to  assure 
equal  employment  opportunities  and  to  term- 
inate racial  segregation  throughout  federal 
services  and  institutions,  and  on  all  govern- 
ment contracts.  The  successful  desegregation 
of  the  armed  services  took  place  through  such 
decisive  executive  action  under  President 
Truman. 


Similarly  the  new  Democratic  administra- 
tion will  take  action  to  end  discrimination  in 
federal  housing  programs,  including  federal- 
ly-assisted housing. 

To  accomplish  these  goals  will  require  ex- 
ecutive orders,  legal  actions  brought  by  the 
Attorney  General,  legislation,  and  improved 
Congressional  procedures  to  safeguard  ma- 
jority rule. 

Above  all,  it  will  require  the  strong,  active 
persuasive,  and  inventive  leadership  of  the 
President  of  the  United  States. 

^ =1:  t-  * * 

The  Democratic  President  who  takes  office 
next  January  will  face  unprecedented  chal- 
lenges. His  administration  will  present  a new 
face  to  the  world. 

It  will  be  a bold,  confident,  affirmative  face. 
We  will  draw  new  strength  from  the  univer- 
sal truths  which  the  founder  of  our  party  as- 
serted in  the  Declaration  of  Independence  to 
be  "self-evident." 

Emerson  once  spoke  of  an  unending  contest 
in  human  affairs,  a contest  between  the  Party 
of  Hope  and  the  Party  of  Memory. 

For  eight  years  America,  governed  by  the 
Party  of  Memory,  has  taken  a holiday  from 
history. 

As  the  Party  of  Hope  it  is  our  responsibility 
and  opportunity  to  call  forth  the  greatness  of 
the  American  people. 

In  this  spirit,  we  hereby  rededicate  our- 
selves to  the  continuing  service  of  the  Rights 
of  Man — everywhere  in  America  and  every- 
where else  on  God's  earth. 


180 


J.  M.  A.  ALABAMA 


Blue  Cross-Blue  Shield 
And  The  Alabama  Doctor 


Joe  Vance 


The  time  has  come  to  speak  out  plainly  and 
to  the  point  regarding  the  relationship  be- 
tween medicine,  Blue  Cross-Blue  Shield,  and 
other  voluntary  hospital  and  medical  care 
prepayment  plans. 

It  is  my  observation  that  only  the  extreme 
conservative  in  the  medical  community  now 
clings  to  the  theory  that  there  is  no  need  or 
place  for  the  third  party  in  the  medico-eco- 
nomic picture.  Except  for  the  uninsured — a 
big  minority — there  remain  only  two  other 
mechanisms  through  which  the  public  can 
pay  for  hospital  and  medical  care.  They  are 
voluntary  prepayment  and  the  federal  gov- 
ernment. 

Briefly,  let  us  list  the  major  factors  that  in- 
fluence cost  of  health  protection.  They  are: 
(1)  Hospital  cost;  (2)  The  cost  of  medical 
care,  as  reflected  in  the  doctor’s  fees;  (3)  The 
greater  use  of  hospital  and  medical  care;  (4) 
Another  factor — and  one  often  overlooked — 
is  the  un-met  cost  of  care  of  the  indigent  pa- 


Mr.  Vance  is  vice  president  of  Blue  Cross-Blue 
Shield  of  Alabama. 


tient.  This  factor  causes  hospitals  to  “load” 
their  charges  up  to  $2  and  $3  per  patient  day 
in  order  to  compensate  tor  community  failure 
adequately  to  support  the  indigent;  (5) 
Abuse  due  to  unnecessary  admissions  and 
long  hospital  stays;  (6)  Sick  and  accident 
coverage  which  together  with  comprehensive 
hospital  coverage  encourages  use. 

Brief  comments  on  each  of  these  major  fac- 
tors are  pertinent. 

Hospital  costs  in  Alabama  are  rising  at  an 
average  rate  of  more  than  8 per  cent  per  year. 
Most  of  this  increase  is  due  to  the  increase  in 
salaries  of  hospital  employees.  Other  major 
contributors  to  increased  costs  are  higher 
drug  costs,  the  increased  cost  and  use  of  lab- 
oratory and  X-ray  departments,  the  refine- 
ment of  the  anesthesia  departments  where 
throughout  our  state  professional  anesthesi- 
ology has  expanded  rapidly,  capital  cost,  and 
the  additional  expense  of  operating  new  and 
updated  old  equipment  (which  are  products 
of  medical  research) . 

In  pointing  out  the  cost  increase  of  pharma- 
cy, laboratory.  X-ray,  and  anesthesia  services. 


SEPTEMBER  I960— VOL.  30,  NO.  3 


181 


THE  ASSOCIATION  FORUM 


it  is  also  important  to  emphasize  that  the 
quality  of  services  has  also  been  raised.  Bet- 
ter quality  costs  more. 

Doctors’  fees  have  increased,  though  not  as 
rapidly  as  general  hospital  costs.  The  fact 
that  medical  fees  have  not  increased  as  rapid- 
ly as  hospital  costs  does  not  mean,  however, 
that  the  doctor  does  not  have  a direct  respon- 
sibility for  and  influence  on  hospital  costs. 

Use  by  the  public  of  both  doctor’s  services 
and  hospital  services  have  increased.  Per- 
haps of  all  the  cost  factors,  the  use  factor  is 
the  most  widely  debated  and  most  completely 
misunderstood. 


Increased  Use  That  Is  Desirable 

If  there  had  not  been  increased  use  of  the 
doctor’s  services  and  of  the  hospital,  we 
should  not  have  the  high  level  medical  care 
to  which  we  have  become  accustomed  and 
which  the  public  demands.  More  hospital 
beds,  improved  diagnostic  and  treatment 
techniques,  and  prepaid  hospital  and  medical 
care  all  tend  to  increase  the  use  of  hospital 
facilities. 

It  therefore  would  be  expected  that  more 
and  more  use  will  be  made  of  hospital  and 
medical  services.  This  is  as  it  should  be.  But 
when  a discussion  of  the  cost  of  these  services 
arises.  Blue  Cross  and  the  doctor  go  on  the 
defensive.  Too  often,  each  blames  the  other. 

At  the  beginning  of  any  discussion  of  use- 
versus-abuse,  all  parties  usually  can  agree  on 
the  altruism  that  only  those  needing  hospital 
care — as  distinguished  from  home  and  office 
medical  treatment — should  be  hospitalized. 
It  is  here  that  medical  need  becomes  subject 
to  the  decision  of  the  doctor.  It  is  here  that 
social  and  socio-economic  factors  enter.  It  is 
here  that  the  doctor’s  decision  may  actually 
affect  the  growth  and  preservation  of  his 
practice. 

A New  Jersey  Blue  Cross  Rate  Study  Com- 
mittee recently  reported  its  findings  to  the 
Commissioner  on  Banking  and  Insurance. 

The  New  Jersey  committee  undertook  to 
investigate  the  causes  for  Blue  Cross  hos- 
pital rate  increases  in  that  state.  No  attempt 


was  made  to  analyze  the  Blue  Shield  or  medi- 
cal rates. 

Hospital  costs  for  the  five  year  period  from 
1953  through  1958  were  studied.  Costs  were 
broken  down  into  (1)  hospital  care  or  “hotel 
care”  costs,  which  included  such  departments 
as  dietary,  housekeeping,  laundry,  plant  oper- 
ation and  maintenance,  and  administration; 
(2)  medical  care  costs,  coming  from  such  de- 
partments as  medical  supply,  general  profes- 
sional care  (including  interns,  residents,  and 
nurses),  and  specialty  departments  (labora- 
tory, X-ray,  EKG,  etc.). 

Based  on  patient  day  costs,  it  was  found 
that  the  so-called  “hotel  area”  costs  advanced 
18.5%  while  medical  care  area  costs  advanced 
42.5%).  Thus,  of  the  total  increase  which  av- 
eraged 32.4%.  over  the  five  year  period,  7.8% 
of  the  increase  was  due  to  “hotel  area”  costs; 
and  24.6%  was  due  to  the  medical  care  area. 

Commenting  on  its  own  analysis,  the  New 
Jersey  committee  said,  “The  hospital  admin- 
istration generally  is  involved  in  the  emer- 
gence of  costs  which  have  gone  up  7.8%.  of 
the  total  per  diem  (1958  over  1953).  The 
medical  profession,  either  through  the  deci- 
sions of  the  individual  doctor  or  the  hospital 
staff  or  the  influences  of  their  professional 
bodies,  local  or  national,  is  involved  in  an  in- 
crease in  costs  equal  to  24.6%  of  the  per  diem 
costs.” 

Commenting  further,  the  committee  report 
said,  “Now  we  must  bring  in  the  other  com- 
ponents of  admission  and  length  of  stay,  and 
on  these  two  we  again  have  to  look  to  the  in- 
dividual doctor  who  determines  both  the 
propriety  of  admission  of  the  patient  and  the 
length  of  his  stay.  These  two  factors  com- 
bine to  produce  a utilization  rate  12.1%  high- 
er in  1958  than  in  1953.” 

One  of  the  conclusions  of  the  Committee 
was:  “This  analysis  leads  one  to  the  inescap- 
able conclusion  that  the  medical  influences, 
as  they  are  exerted  by  doctors  individually, 
in  staff,  and  through  their  professional  bod- 
ies, are  five  times  as  great  a factor  in  the  in- 
crease in  hospital  costs  as  all  the  other  in- 
fluences the  hospitals  have  to  encounter  in 
their  services.” 


182 


J.  M.  A.  ALABAMA 


THE  ASSOCIATION  FORUM 


Blue  Cross-Blue  Shield  Shortcomings 

Perhaps  the  inadequacies  of  Blue  Cross- 
Blue  Shield  should  be  discussed  here.  In  or- 
der to  understand  the  present  health  cover- 
age of  the  Alabama  Plan,  it  is  necessary  to 
review  the  origin  of  the  Plan.  It  was  organ- 
ized in  1936  by  a group  of  doctors  and  hos- 
pital administrators  for  the  sole  purpose  of 
paying  hospital  bills.  Hospital  beds  were 
empty  because  the  people  could  not  afford 
them.  As  a result  of  the  hospital  situation, 
doctors  were  restrained  from  treating  many 
of  their  patients  for  reasons  of  economy. 

Then  in  1946,  the  Medical  Association  of 
the  State  of  Alabama  asked  Blue  Cross  to 
write  a medical-surgical  rider  to  the  hospital 
contract.  With  the  reserves  of  the  hospital 
corporation,  the  Alabama  Plan  wrote  and  fi- 
nanced— at  a considerable  economic  loss  for 
several  years — a medical-surgical  rider  which 
was  designed  primarily  to  pay  part  of  the  sur- 
gical fees  and  to  pay  for  a small  amount  of 
the  in-hospital  medical  care  ($3  per  day).  It 
was  the  judgement  of  the  Blue  Cross  Board 
in  1946  that  since  the  majority  of  hospital 
cases  were  surgical  and  obstetrical,  the  major 
coverage  should  be  for  those  cases. 

Since  the  medical-surgical  rider  was  an  in- 
demnity contract  and  was  intended  to  pay 
only  part  of  the  doctors’  fees,  there  was  no 
necessity  for  the  doctors  to  sign  any  agree- 
ment as  participating  doctors. 

Despite  the  fact  that  the  doctors  then,  as 
today,  had  a voice  in  the  government  of  Blue 
Cross-Blue  Shield  of  Alabama  (one-third  of 
the  Board  of  Directors  are  doctors) , they 
were  not  asked  to  contribute  financially  to 
the  launching  of  the  Plan.  Nor  were  the  doc- 
tors asked  to  accept  the  Blue  Shield  pay  al- 
lowance as  full  payment.  It  is  important  to 
labor  this  point  because  the  member  hospitals 
(now  130  of  them)  accept  the  Blue  Cross  pay- 
ment as  full  compensation  for  the  services 
covered  under  the  hospital  contract. 

The  agreement  signed  by  member  hospitals 
requiring  a membership  fee  goes  further.  The 
so-called  Inter-Hospital  Service  Agreement 
stipulates  that  should  Blue  Cross  be  unable 
to  pay  the  amount  due  the  member  hospitals 


for  services,  these  hospitals  would  agree  to 
accept  proration  of  payment. 


The  Effect  of  the  Kate  of  Admission 

As  prepayment  of  hospital  and  doctor  care 
has  evolved  in  the  state  and  nation,  it  has  be- 
come increasingly  apparent  that  public  and 
doctors  feel  that  more  outpatient  and  doctor 
office  diagnostic  procedures  should  be  cov- 
ered. 

Perhaps  one  of  the  most  frequent  com- 
plaints heard  is  the  one  which  decries  the 
lack  of  coverage  for  out-of-hospital  medical 
and  diagnostic  care.  Some  patients,  in  all 
honesty,  urge  their  doctors  to  hospitalize 
them  in  order  that  certain  diagnostic  tests 
may  be  performed  and  covered  by  Blue 
Cross.  Although  diagnostic  studies  are  ex- 
cluded in  most  Blue  Cross-Blue  Shield  con- 
tracts, we  know  that  nevertheless  many  such 
admissions  occur. 

Because  of  the  diagnostic  exclusion  along 
with  admissions  for  minor  conditions  such  as 
gastritis,  pneumonitis,  avitaminosis,  uncom- 
plicated influenza,  and  the  like,  accumulated 
Blue  Cross  data  has  shown  an  increase  in  ad- 
missions rates  per  1,000  for  Alabama  sub- 
scribers of  from  129  in  1954  to  145  in  1959.  It 
is  true  that  the  admission  rate  should  be  ex- 
pected to  rise;  but  with  a mass  of  data  show- 
ing one  and  two-day  hospital  stays  for  the 
usually  minor  conditions  (such  as  pneumoni- 
tis, gastritis,  etc.),  it  is  apparent  that  there 
are  certainly  both  diagnostic  and  unnecessary 
admissions — when  judged  by  competent  med- 
ical men.  Review  of  hospital  charts  confirms 
this  fact. 

In  view  of  the  demand  by  public  and  doc- 
tors for  diagnostic  and  out-of-hospital  cov- 
erage, it  is  certainly  true  that  Blue  Cross  and 
Blue  Shield  should  lead  the  way  to  such  ad- 
ditional coverage.  Several  large  Alabama 
groups  already  have  this  protection.  An  esti- 
mated 10  per  cent  of  Alabama’s  768,000  mem- 
bers have  diagnostic  coverage.  Nevertheless, 
diagnostic  coverage  failed  to  reduce  in-hos- 
pital use  among  these  members. 


SEPTEMBER  I960— VOL.  30,  NO.  3 


183 


THE  ASSOCIATION  FORUM 


But  such  coverage  usually  is  obtained  as  a 
fringe  benefit  at  the  bargaining  table.  What 
of  the  other  90  per  cent? 

It  is  the  judgement  of  responsible  Blue 
Ci’oss  and  Blue  Shield  officials  that  if  some 
means  of  controlling  abuse  of  both  inpatient 
and  out-of-hospital  service  could  be  devised, 
Blue  Cross  and  Blue  Shield  could  immediate- 
ly begin  to  write  such  coverage.  It  is  also 
the  judgement  of  these  Blue  Cross  officials 
that  the  active,  sincere  cooperation  of  the 
medical  profession  is  the  only  valid  means 
of  controlling  abuse.  Tissue  committees  in 
accredited  hospitals  have  raised  surgical 
standards  and  incidentally  discouraged  un- 
necessary surgery. 

Whether  it  be  an  independent  medical  re- 
view board,  periodic  medical  review  by  each 
hospital  medical  staff,  or  a combination  of 
the  two  is  something  to  be  decided  by  the 
doctors  themselves.  To  wait  until  the  State 
Insurance  Commissioner  orders  medical  con- 
trols is  to  wait  too  long. 

But  no  progress  can  be  made  by  saying  that 
only  a few  doctors  and  patients  are  abusing 
their  insurance  and  that,  thex'efore,  no  prob- 
lem really  exists. 

To  be  sure,  a relatively  few  doctors  and  pa- 
tients actually  defraud  insurance  carriers. 
These  are  very  easy  to  spot;  and  while  such 
fraud  sometimes  can  be  a sizeable  factor,  in 
the  aggregate,  fraud  is  but  a minor  part  of 
the  problem.  Rather,  carelessness  and  ra- 
tionalization are  the  problems. 


The  Effect  of  Length  of  Stay 

At  the  other  end  of  the  hospital  admissions, 
another  area  is  subject  to  abuse.  It  is  the  un- 
necessarily long  stay  and  the  long  stay  par- 
tially caused  by  the  failure  of  Blue  Cross  to 
provide  for  home  and  nursing  home  care. 
Both  the  unnecessarily  long  stay  and  the  long 
stay  due  to  inadequate  out-of-hospital  insur- 
ance coverage  can  be  solved. 

Organized  medical  review  by  the  medical 
profession  can  evaluate  the  unnecessarily 


long  hospital  stay  by  judging  each  admission 
on  its  own  medical  merits. 

A Home  Care  Program 

Blue  Cross  is  already  attacking  the  inade- 
quate coverage  problem.  With  its  Pilot  Home 
Care  Program  in  cooperation  with  the  Visit- 
ing Nursing  Association  of  Jefferson  County, 
Blue  Cross  and  cooperating  doctors  in  the 
short  span  of  five  and  a half  months  have  al- 
ready demonstrated  the  effectiveness  of  a 
home  care  program. 

Here  are  some  preliminary  figures  gained 
from  operating  this  program  in  six  Birming- 
ham hospitals: 

(1)  An  estimated  655  hospital  days,  valued 
at  $18,176.55,  have  been  saved. 

(2)  Using  the  Birmingham  average  hospi- 
tal stay  of  7.2  days,  this  means  that  91  more 
patients  probably  have  been  able  to  gain  ad- 
mission to  the  overflowing  Birmingham  hos- 
pitals. 

(3)  80.6  per  cent  of  the  cases  discharged 
earlier  to  their  homes  by  their  doctors  have 
been  medical  cases. 

(4)  19.4  per  cent  of  the  cases  were  surgical, 
many  of  them  terminal  cancer. 

(5)  Based  on  the  approximate  cost  of  op- 
erating this  program  and  paying  the  Visiting 
Nursing  Association  for  the  home  visits,  a 
net  savings  of  about  $14,521.25  has  been  real- 
ized. 

These  savings,  if  applied  to  our  experience 
in  all  hospitals  in  Birmingham,  Montgomery, 
and  Mobile,  could  be  a real  factor  in  forestall- 
ing a possible  rate  increase  in  the  not-too- 
distant  future. 

Because  of  the  success  of  this  experiment  in 
such  a short  time,  the  Mobile  County  Medical 
Society  has  authorized  Blue  Cross  to  begin 
a home  care  program  there. 


184 


J.  M.  A.  ALABAMA 


THE  ASSOCIATION  FORUM 


The  Cost  of  Longer  Stays 

The  reality  and  worthwhileness  of  reduc- 
ing the  length  of  stay  in  the  hospital  is  graph- 
ically revealed  by  the  following  calculations, 
based  on  Alabama  Blue  Cross  experience  in 
1954  as  compared  with  1959. 

The  average  length  of  stay  in  Alabama  hos- 
pitals in  1954  was  5.99  days.  For  1959  it  was 
6.57  days,  or  a rise  of  a little  more  than  one- 
half  of  a day.  There  were  about  111,000  Blue 
Cross  admissions  in  1959.  If  the  average 
length  of  stay  had  remained  at  the  1954  figure 
of  5.66  days,  some  62,160  hospital  days  would 
have  been  saved. 

Converting  these  hospital  days  to  money 
by  evaluating  them  at  $25  per  day,  $1,554,000 
would  have  been  cut  off  the  patients’  hospi- 
tal bills.  Such  an  amount  as  this  would  have 
undoubtedly  made  the  Blue  Cross  rate  in- 
crease of  April  1959  either  unnecessary  or,  at 
least,  less  drastic. 

While  it  is  possible  to  explain,  in  part,  the 
increase  in  the  number  of  admissions,  it  is 
much  harder  to  explain  and  justify  the  in- 
crease in  average  length  of  stay.  To  the  con- 
trary, hospitals  and  doctors  today  point 
proudly  to  the  diminishing  length  of  stay. 
This  is  not  true  in  Alabama. 


Sh  m mary 

If  the  problems  of  broader  coverage  and 
control  of  cost  are  to  be  met  in  a voluntary, 
free  enterprise  manner,  much  closer  coordi- 
nation must  be  established  between  organ- 
ized medicine,  organized  hospitals,  and  the 
local  Blue  Cross  and  Blue  Shield  Plans. 

First,  there  must  be  a recognition  by  the 
health  parties  that  basic  problems  actually 
do  exist.  In  the  face  of  a continued  increase 
in  cost: 

(1)  Hospitals  cannot  fail  to  examine  every 
internal  procedure,  every  buying  habit  with 
a view  of  obtaining  maximum  efficiency  and 
optimum  use  of  their  facilities. 


(2)  Hospitals,  out  of  pride  of  possession, 
cannot  afford  to  install  every  new  diagnostic 
or  treatment  device  but  must  share  some  of 
the  ultra-expensive  innovations. 

(3)  Nor  should  hospitals  build  additional 
beds  until  the  need  tor  those  beds  by  type  has 
been  clearly  established  in  the  community 
by  competent  authority. 

(4)  Hospitals  should  insist  that  a hospital 
authority  in  each  community  be  activated  for 
the  purpose  of  evaluating  hospital  needs. 

In  the  face  of  documented  irresponsible  use 
of  hospital  facilities  and  the  public  demand 
for  broader  health  protection: 

(1)  Doctors  must  examine  their  own  prac- 
tices and  those  of  their  colleagues,  using  the 
highest  quality  medical  yardstick. 

(2)  They  must  work  with  hospitals  and 
the  responsible  public  body  in  order  to  edu- 
cate the  public  in  the  proper,  efficient  use  of 
their  expensive  health  facilities. 

(3)  Having  insured  efficient  use  of  these 
health  facilities,  doctors  must  work  more 
closely  with  their  local  Blue  Cross  and  Blue 
Shield  Plan  in  order  to  develop  the  broader 
protection  which  the  doctor  requires  and  the 
public  demands. 

(4)  A medical  liaison  committee  of  the 
Jefferson  County  Medical  Society  has  been 
functioning  tor  the  past  half  year,  and  with 
a good  deal  of  success.  Liaison  committees 
representing  all  of  Alabama’s  county  medical 
societies  should  be  established. 

(5)  The  medico-economic  facts  of  life  with 
reference  to  health  insurance  should  be 
taught  in  the  Medical  College.  Most  new 
doctors  enter  practice  poorly  grounded  in 
what  is  to  be  their  major  source  of  income — 
the  third  party  payer. 

Failure  to  act  will  result  in  the  pyramiding 
of  cost  of  health  protection  to  the  point  where 
the  cost  will  be  beyond  the  reach  of  the  great 
mass  of  Alabamians. 


SEPTEMBER  I960— VOL.  30,  NO.  3 


185 


The  Decade  Ahead 


It  has  been  said  that  since  1946,  the  gross 
national  product  has  more  than  doubled.  The 
fact  is,  of  course,  that  it  has  done  no  such 
thing.  For  when  we  take  into  account  the 
ravages  of  inflation  and  translate  the  1946 
figure  into  today’s  dollars,  we  find  that  our 
growth  has  not  been  at  a rate  of  six  per  cent 
a year  but  at  just  about  half  of  that  rate. 
Looking  from  another  direction,  in  that  peri- 
od the  purchasing  power  of  the  dollar  has  lost 
a third  of  its  value.  Steadily,  year  after  year, 
the  cost  of  living  has  climbed,  eroding  eco- 
nomic values,  and  making  it  increasingly 
more  difficult  for  businessmen  to  plan  their 
operations  and  customers  their  purchases. 

If  there  is  any  consolation  at  all,  it  is  that 
there  is  a growing  awareness  of  the  evil  of 
inflation.  Yet  the  disheartening  fact  remains 
that  four  out  of  ten  Americans  either  don’t 
know  what  to  think  or  actually  believe  infla- 
tion is  something  beneficial.  And  I have  sus- 
pected for  some  time  that  the  degree  of  ig- 
norance of  inflation’s  damaging  effects  is  in- 


Mr.  Paxton  is  president  of  the  General  Electric 
Corporation. 


Robert  Paxton 


versely  proportional  to  age.  Older  groups, 
say  over  45,  have  lived  with  and  experienced 
inflation  as  it  has  eroded  purchasing  power, 
savings,  and  pensions.  Younger  people,  say 
from  21  to  29,  have  not  learned  these  lessons 
first  hand.  Too  often,  they  have  had  contact 
with  only  doubtful  economic  teaching  or,  fre- 
quently, with  no  instruction  at  all. 

The  actions  of  three  groups  have  clearly 
contributed  to  the  inflation-ridden  condition 
in  which  the  economy  now  finds  itself. 

One  of  these  guilty  groups  is  government. 

Today  government  and  its  agencies  togeth- 
er have  become  an  automated  engine  of  in- 
flation, complete  with  a feedback  circuit  that 
continually  adjusts  the  machine  to  the  de- 
mands of  special  interests  as  it  produces  a 
continuous  stream  of  deteriorated  values  and 
mounting  distortions  within  the  economy. 
This  is  not  an  uncommon  view.  Regardless 
of  ideological  orientation,  there  is  virtually 
unanimous  agreement  that  Federal  spending 
is  an  inflationary  instrument. 

About  20  per  cent  of  the  gross  national 
product  is  now  deflected  through  the  federal 


186 


J.  M.  A.  ALABAMA 


THE  ASSOCIATION  FORUM 


channels.  All  governments — federal,  state, 
and  local — take  about  30  per  cent  of  our  na- 
tional income.  Defense  spending,  of  course, 
is  a major  factor  today;  and  we  cannot  escape 
spending  whatever  is  necessary  to  maintain 
our  national  strength. 

But  defense  spending  since  1954,  for  exam- 
ple, has  for  all  practical  purposes  remained 
level  while  non-defense  spending,  stimulated 
by  every  conceivable  kind  of  excuse,  has  ex- 
panded by  some  ten  billions  in  the  same  pe- 
riod for  the  federal  government  alone.  Such 
stimulation  helped  to  produce  national  bud- 
gets some  fifteen  times  larger  than  the  years 
when  national  policy  was  to  “spend  and 
spend  and  spend.” 

In  addition,  what  is  substantially  a nation- 
al conspiracy  to  inflate  our  federal  budgets  Is 
aided  and  abetted  by  deficit  spending.  In 
only  four  years  since  World  War  II  has  the 
federal  government  been  in  the  black.  In 
every  other  peacetime  year  we  have  accum- 
ulated deficits  of  as  much  as  12  V2  billions. 
The  interest  on  the  national  debt  has  more 
than  doubled  since  1946  and  is  now  about  two 
and  a half  times  what  we  spend  in  this  coun- 
try for  higher  education.  No  wonder  we 
have  to  do  business  with  60-cent  dollars. 

All  of  the  country’s  bureaucrats,  however, 
are  not  in  government;  nor  is  government  the 
sole  perpetrator  of  inflation.  In  all  good  con- 
science, we  who  manage  today’s  businesses 
must  realize  that  we  share  a responsibility  in 
restraining  inflation.  When  we  deny  that 
responsibility,  we  participate  equally  with 
all  other  groups  in  promoting  inflation. 

For  almost  fifteen  years  now,  we  have  been 
careless  about  costs.  We  have  concentrated 
on  output,  disregarding  as  much  as  possible 
the  cost  of  input.  And  in  operating  on  a large 
margin  of  waste,  too  many  managers  have 
found  that  the  customer  is  a convenient  out: 
it  is  simpler  to  raise  prices  than  to  raise  Cain 
with  slipshod  methods. 

Management  in  too  many  instances  has  not 
resisted  the  inflationary  demands  of  union 
officials  and  has  made  little  attempt  to  ex- 


plain that  cost  increases  without  commensu- 
rate changes  in  value  are  never  justified. 

To  stand  firm  in  the  face  of  circumstances 
that  must  add  to  the  cost  of  living  is  not  an 
anti-union  position.  Nor  is  it  in  any  sense 
class  warfare  as  some  union  officials  are  spe- 
ciously claiming.  A refusal  to  surrender  to 
the  inflationary  ultimatum  of  a union  offi- 
cial is  in  fact  pro-employee  and  pro-public.  It 
helps  to  insure  continuity  of  employment  for 
the  union  members  themselves  and  stability 
of  prices  for  the  public.  On  the  other  hand, 
wage  inflation  directly  destroys  employment 
and  causes  inflation.  For  this,  management, 
union  officials,  and  government  must  all 
share  accountability. 

Today,  many  union  leaders  are  entrenched 
in  what  are  monopolistic  positions,  protected 
and  insulated  from  their  own  constituencies 
and  bent  on  furthering  only  their  own  aspira- 
tions, as  the  McClellan  Committee  hearings 
documented  so  clearly. 

In  the  first  eight  weeks  of  the  new  Lan- 
drum-Griffin  law,  for  example,  the  Justice 
and  Labor  departments  received  over  500 
mail  complaints  of  union-leader  malfeasance 
of  one  kind  or  another.  What  is  more,  the  in- 
creasing tendency  for  the  big  unions  to  join 
together  in  national  combines  can  only  weak- 
en further  the  position  of  local,  responsive 
union  officials.  And  from  their  protected  po- 
sitions of  power,  many  union  leaders  can  con- 
sistently make  and  often  enforce  demands 
that  do  not  bear  any  reasonable  relationship 
to  operable  cost  structures.  Consequently, 
prices  have  risen  simply  because  there  was 
no  more  give  left  in  the  system. 

As  prices  more  and  more  are  insulated 
from  the  corrective  drives  established  by  the 
market  place,  more  and  more  they  fail  to  re- 
flect gains  in  productivity.  For  when  wage 
increases  are  granted  without  recourse  to 
market  considerations  and  in  response  to  un- 
ion monopoly  power  or  political  pressure, 
they  cannot  help  cancelling  out  the  gains 
available  from  productivity  considerations. 
The  results  must  be  inflationary. 

Technicalities  aside  for  the  moment,  the 
over-riding  fact  that  we  must  keep  before  us 


SEPTEMBER  I960— VOL.  30,  NO.  3 


187 


THE  ASSOCIATION  FORUM 


— that  we  must  constantly  emphasize  for  our 
fellow  employees,  our  neighbors,  government 
officials,  and  the  public  generally — is  this: 

Wages  are  paid  by  customers  and  not  by 
owners.  Unions  are  actually  bargaining  not 
about  the  owner’s  ability  to  pay  but  about  the 
customer’s  ability  and  willingness  to  pay.  The 
customer  can  pay  us,  or  a domestic  competi- 
tor, or  a foreign  competitor,  or  a producer  of 
a substitute  product.  Or  the  customer  may 
simply  decide  to  do  without.  It  is  his  choice 
and  no  one  else’s. 

The  failure  to  understand  who  pays  wages 
is  probably  why  there  is  so  much  discussion 
of  whether  productivity  is  the  rich  man’s 
friend  or  the  poor  man’s  friend.  It  seems  to 
me  that  people  a hundred  years  from  now 
will  look  back  on  us — and  I think  most  of  us 
will  look  back  on  ourselves  ten  years  from 
now — and  wonder  how  in  the  world  so  many 
of  us  went  on  giving  the  totally  wrong  an- 
swer to  this  question: 

Can  we  all  live  better  by  each  doing  less 
and  less  for  other  people  while  expecting 
them  to  do  more  and  more  for  us? 

When  wage  rates  are  pushed  up  by  union- 
leader  pressure  beyond  increases  in  the  na- 
tional productivity  rate,  several  things  hap- 
pen. Companies  whose  own  productivity 
rates  are  higher  than  the  national  figure  can- 
not raise  wages  without  producing  inflation- 
ary effects,  because  of  their  influence  on  the 
settlements  of  others  less  favorably  situated. 
They  create  an  upward  pressure  on  labor 
market  prices  that  low  productivity  firms 
cannot  possibly  meet  without  adding  to  their 
costs.  Simultaneously,  high  cost  industries 
find  it  difficult  to  compete  domestically.  They 
lose  customers;  the  number  of  jobs  are  re- 
duced; profits  approach  the  vanishing  point, 
and  consequently  x’einvestment  in  new  ma- 
chinery and  equipment  that  could  reverse 
their  productivity  trend  tends  to  be  fore- 
closed. 

U.  S.  exports  for  many  years  have  exceeded 
imports  by  over  three  billion  dollars  annual- 
ly. By  last  year,  the  difference  had  been 
trimmed  to  one  billion  dollars.  And  in  a num- 


ber of  important  industries,  imports  actually 
exceed  exports. 

Our  overall  imports  hit  an  all  time  high  of 
15  billion  dollars;  and  the  gain  in  1959  over 
1958  amounted  to  16  per  cent,  the  biggest  in 
our  history.  Similarly,  exports  continued 
their  downward  trend  prevalent  in  1958.  In 
several  industries,  American  producers  are 
being  outproduced,  underpriced,  and  outsold 
by  foreign  competition.  Inflation,  of  course, 
is  an  important  contributor  to  the  difficulties 
in  which  we  find  ourselves.  But  it  is  a culprit 
only  because  of  our  failure  to  improve  our 
rates  of  productivity  and  keep  wage  rates 
from  outpacing  productivity. 

We  have  begun  to  learn  that  we  have  no 
exclusive  monopoly  of  technology.  France, 
Germany,  Japan,  Italy,  and  Great  Britain 
have  rebuilt  from  the  rubble  of  war  and  now 
have  in  place  facilities  consistent  with  the 
highest  technological  developments.  They 
have  improved  marketing  techniques,  and  in 
many  cases  they  have  been  able  to  overcome 
the  disadvantage  of  delivery  time. 

It  seems  to  us  that  a basic  objective  of  un- 
ion leaders  should  be  to  maximize  productive 
employment  rather  than  defend  practices 
which  must  lead  inescapably  to  a loss  of  jobs, 
as  our  experience  with  foreign  competition 
illustrates  so  sharply.  Union  members  gen- 
erally understand  this  need  and  also  under- 
stand the  need  to  concentrate  on  efficient 
production.  Nor  can  we  assume  that  union 
leaders  lack  such  understanding.  Rather,  they 
seem  to  think  that  the  exigencies  of  union 
politics  require  their  opposition  and  thus  ab- 
dicate from  the  exercise  of  true  leadership. 

We  have  a tremendous  growing  and  dan- 
gerous problem  with  unions — the  problem  of 
handling  massive  excess  economic  and  politi- 
cal powers  that  the  public  did  not  intend  un- 
ion officials  to  have  but  which  they  exercise 
nevertheless  over  workers,  employers,  con- 
sumers, law-makei's,  and  law  enforcement  of- 
ficials. 


188 


J.  M.  A.  ALABAMA 


THE  ASSOCIATION  FORUM 


To  help  employees  and  the  x'est  of  the  pub- 
lic achieve  correction  of  these  evils,  business- 
men will  need  to  develop  political  knowledge 
and  skills.  Such  proficiency  will  also  make 
them  constructively  effective  in  areas  where 
their  political  activity  is  needed  in  order  to 
free  business  to  be  fully  useful  to  all  the  pub- 
lic. Let’s  examine  how  the  union  officials  ac- 
quired such  an  excess  of  power.  For  the  na- 
ture, extent,  and  unintended  consequences 
of  that  power  are  not  yet  understood  by  the 
public;  and  no  correction  can  come  until  the 
public  does  understand.  And,  not  until  the 
public  does  understand  will  the  correction  be 
supplied  by  political  candidates  or  office 
holders. 

Workers  and  the  public  quite  rightly  want- 
ed employees — where  they  wished  to  bring 
their  strength  up  equal  with  that  of  their  em- 
ployer— to  have  the  right  of  bargaining  col- 
lectively with  their  employer.  This  was 
good!  But  subsequent  legislation  and  prac- 
tice since  the  Wagner  Act  have  enabled  un- 
ion officials  to  acquire  what  is  virtually  a 
broad,  monopoly  power,  in  some  cases 
spreading  across  whole  industries.  Indeed, 
in  no  other  area  of  the  economy  has  the  pub- 
lic granted,  much  less  stood  for,  such  exten- 
sive control  by  a particular  group.  It  is  the 
basic  factor  in  preventing  the  kind  of  true 
and  genuine  collective  bargaining  intended 
by  the  public  and  in  substituting  the  dictated, 
inflationary,  and  debilitating  settlements 
that  we  have  become  accustomed  to. 

The  companion  opportunity  given  under 
both  the  Wagner  and  Taft-Hartley  enables 
union  officials  on  economic  and  political  proj- 
ects selected  by  the  union  officials  with  lit- 
tle or  no  supervision  or  recourse  by  members. 
This  flood  of  easy  income,  immune  from 
member  control,  is  the  basic  source  of  the 
political  power  of  union  officials.  They  can 
and  do  use  the  pressures  of  money  and  man- 
; power  directly  on  government.  And  they  use 
! that  power  indirectly  on  government  by 
>.  teaching  to  the  constituents  of  public  serv- 
! ants  their  particular  view  of  economics  and 
I public  issues,  which  urges  deficit  spending 
I and  evermore  concentration  of  activities  in 
' : Washington. 

1 i SEPTEMBER  I960— VOL.  30,  NO.  3 


Another  facet  of  the  problem  is  the  vio- 
lence which  union  officials  are  privileged  to 
employ  both  legally  and  illegally.  Violence 
— whether  real  or  only  threatened — has  be- 
come a powerful  force  in  implementing  un- 
ion official  power  over  the  persons  and  sav- 
ings of  workers,  employers,  consumers,  gov- 
ernment officials,  and  the  rest  of  the  public. 
Every  citizen  should  feel  a deep  sense  of 
shame  in  the  presence  of  violence,  actual  or 
threatened,  a condition  so  alien  to  our  funda- 
mental beliefs.  As  so  few  know,  the  threat  of 
privileged  violence  is  what  lends  an  appear- 
ance of  peace  to  so  many  so-called  labor  dis- 
putes. 

Sympathetic,  public  understanding  of  the 
need  for  political  work  will  depend  on  the 
integrity  of  our  actual  efforts  and  on  the  de- 
gree to  which  we  managers  emphasize  that 
leadership;  and  credibility  will  go  to  those 
who  can  offer  convincing  workable  solutions 
to  the  nation’s  problems. 

It  would  be  easier,  of  course,  to  let  things 
drift;  but  if  we  do,  the  essence  of  democracy 
would  be  lost.  To  make  certain  that  the  com- 
ing decade  are  years  in  which  business  can 
effectively  serve,  profit,  and  grow  in  the  pub- 
lic interest,  it  needs  to  face  up  to  those  pres- 
sures and  to  call  public  officials  to  account 
when  they  press  for  their  own  political  inter- 
ests contrary  to  the  welfare  of  the  governed. 

The  achievement  of  economic  growth  in  the 
years  ahead  will  require  new  degrees  of  co- 
operation among  management,  employees, 
and  the  public.  Above  all  it  will  demand  that 
management  exhibit  a large  measure  of  mor- 
al courage  and  political  insight.  Exercising 
these  attributes,  the  promise  of  the  future  for 
business  and  the  nation  is  unbounded.  In- 
creasing political  intervention  in  the  affairs 
of  the  economy  and  centralization  must  be  re- 
sisted, and  progress  must  be  accelerated  so 
that  there  will  be  valid  improvement  in 
standards  of  living.  We  must  reinforce  our 
position  of  free  world  leadership.  I have  an 
unshakable  conviction  that  we  can. 


189 


around  the  stalS 


GUEST  SPEAKERS'— Dr.  Waldo 
E.  Nelson,  professor  of  pediatrics 
of  Temple  University  School  of 
Medicine  and  Editor  of  the  Jour- 
nal of  Pediatrics,  left,  and  Dr. 
John  J.  Killeffer,  orthopedic  sur- 


MOBILIAN— Dr.  M.  Vaun  Adams, 
below,  president  of  the  Alabama 
pediatricians  for  the  past  three 
years,  was  succeeded  by  Dr.  Wil- 
liam A.  Daniel  of  Montgomery. 


geon  of  Chattanooga,  below,  were 
among  the  guest  speakers  at  the 
second  annual  meeting  of  the 
Alabama  Chapter  of  the  American 
Academy  of  Pediatrics  at  Point 
Clear  on  September  9-11. 


PROGRAM — The  highly  success- 
ful three  day  program  was  under 
the  direction  of  Dr.  Robert  O. 
Harris,  III,  of  Mobile  who  served 
as  program  chairman  for  the 
second  consecutive  year. 


190 


J.  M.  A.  ALABAMA 


AROUND  THE  STATE 


LADIES  ENTERTAINMENT— 
Mrs.  George  W.  Newburn,  Jr., 
right,  assisted  by  Mrs.  Julius  A. 
Pennington,  entertained  GP  wives 
at  a luncheon  and  fashion  show 
during  the  seminar. 


HONORARY  MEMBER  — 
Dr.  Emmett  Frazer,  promi- 
nent Mobile  surgeon,  is  pic- 
tured above,  right,  receiving 
from  Dr.  James  R.  Garber 
an  honorary  membership  in 
the  Alabama  Academy  of 
General  Practice  during  the 
Academy’s  21st  Postgradu- 
ate Seminar  in  Mobile  on 
August  24. 


PAST  PRESIDENTS  — Twenty-four 
past  presidents  of  the  five  component 
chapters  of  the  Alabama  Academy  were 
awarded  certificates  for  faithful  serv- 
ice as  president  during  the  Mobile 
seminar.  Dr.  Julius  A.  Pennington, 
past  president  of  the  Mobile  chapter, 
left,  is  shown  receiving  his  certificate 
from  Dr.  James  R.  Garber.  Looking  on 
is  Dr.  Winston  A.  Edwards,  president 
of  the  Academy. 


SPEAKER — Dr.  William  D.  Davis,  Jr., 
head  of  the  gastroenterology  depart- 
ment at  Ochsner  Clinic  in  New  Orleans, 
left,  is  shown  discussing  old  school 
days  with  former  classmate  Dr.  Wil- 
liam L.  Smith,  Secretary-Treasurer  of 
the  State  Medical  Association. 


GP’S — from  throughout  the  state  listen 
intently  during  the  OB-GYN  symposi- 
um during  the  first  day  of  the  seminar. 


SEPTEMBER  I960— VOL.  30,  NO.  3 


191 


CENTER  NEWS 


DR.  WUEHRMANN  ACTING  DEAN 
OF  DENTAL  SCHOOL 

Dr.  Arthur  H.  Wuehrmann,  professor  of 
dentistry  and  associate  dean  of  the  School 
of  Dentistry,  will  be  acting  head  of  the  School 
during  the  coming  academic  year.  Dr.  Joseph 
F.  Volker,  dean  of  the  Dental  School  and  di- 
rector of  research  and  graduate  studies  for 
the  Medical  Center,  is  on  a year’s  leave  of 
absence  to  direct  a study  of  Arizona’s  present 
and  anticipated  health  facility  and  personnel 
needs. 

Dr.  Wuehrmann,  who  has  been  associate 
dean  of  the  Dental  School  since  1956,  is  a na- 
tive of  New  Jersey.  He  received  his  under- 
graduate degree  from  Boston’s  Tufts  College 
(now  Tufts  University),  and  graduated  cum 
laude  with  a D.  M.  D.  degree  from  that  col- 
lege’s dental  school  in  1937.  After  interning 
at  Forsyth  Dental  Infirmary  for  Children  in 
Boston,  Dr.  Wuehrmann  spent  approximately 
13  years  in  private  practice  in  the  Boston 


area  while  holding  teaching  positions  at  Tufts 
College  Dental  School. 

In  1951,  Dr.  Wuehrmann  became  associated 
with  the  University  of  Alabama  School  of 
Dentistry  as  professor  and  chairman  of  the 
division  of  restorative  and  prosthetic  den- 
tistry. In  addition  to  his  present  administra- 
tive position,  he  also  holds  consultive  appoint- 
ments in  dental  radiology  at  the  Veterans 
Administration  Hospitals  in  Alabama  and  at 
Martin  Army  Hospital  in  Fort  Benning,  Geor- 
gia. He  is  the  dental  member  of  the  Nation- 
al Advisory  Committee  on  Radiation  to  the 
United  States  Public  Health  Services. 


DR.  BERSON  REAPPOINTED  TO 
ADVISORY  COUNCIL 

The  reappointment  of  Dr.  Robert  C.  Berson 
to  serve  on  the  National  Advisory  Council  on 
Health  Research  Facilities  was  announced  re- 
cently by  Surgeon  General  Leroy  E.  Burney 
of  the  Public  Health  Service,  Department  of 
Health,  Education,  and  Welfare.  Dr.  Berson, 
University  of  Alabama  vice-president  for 
health  affairs  and  dean  of  the  Medical  Col- 
lege, was  originally  appointed  to  the  Council 
in  February  1959,  and  will  now  serve  through 
.August  1961. 

Dr.  Berson,  a native  of  Tennessee,  received 
his  M.  D.  degree  from  Vanderbilt  University 
School  of  Medicine.  He  served  as  an  instruc- 
tor in  clinical  medicine  at  Vanderbilt  and 
later  became  assistant  dean  of  the  medical 
school  there. 

Prior  to  his  present  appointment  to  the 
Council,  Dr.  Berson  was  a special  consultant 
to  that  group  and  to  the  Surgeon  General.  As 
a member  of  the  National  Advisory  Council 
on  Health  Research  Facilities,  Dr.  Berson 
advises  and  makes  recommendations  to  the 


192 


J.  M.  A.  ALABAMA 


MEDICAL  CENTER  NEWS 


Surgeon  General  on  matters  relating  to  the 
federal  program  to  strengthen  the  nation’s 
capacity  for  medical  research  by  construct- 
ing and  equipping  health  research  facilities. 

The  Council  is  one  of  nine  National  Adviso- 
ry Councils  established  as  advisors  to  the 
Public  Health  Service.  The  Division  of  Re- 
search Grants  of  the  National  Institutes  of 
Health  (the  principal  research  center  for  the 
Public  Health  Service)  administers  the 
health  research  facilities  construction  pro- 
gram. 


Lucky  13 — Junior  year  medical  student 
Huey  Green  McDaniel  is  the  recipient  of  the 
13th  annual  Stuart  Graves  Pathology  Award 
for  outstanding  leadership  in  general  patholo- 
gy during  his  sophomore  year.  Since  1948, 
the  Award  has  been  presented  to  a previous 
total  of  14  postsophomore  students  who,  in 
the  opinion  of  the  pathology  department  fac- 
ulty, were  outstanding  in  character,  scholar- 
ship, and  attitude  toward  work  in  the  path- 
ology classes.  The  late  Dr.  Stuart  Graves, 
for  whom  the  Award  is  named,  was  a profes- 
sor of  pathology  and  dean  of  the  two-year 
medical  college  at  the  University  of  Alabama 
campus  from  1928  to  1945.  Mr.  McDaniel,  a 
graduate  of  Shades  Valley  High  School  and 

SEPTEMBER  I960 — VOL.  30,  NO.  3 


the  University  of  Alabama,  is  a native  of 
Birmingham  and  is  affiliated  at  the  Medical 
College  with  the  Sigma  chapter  of  Phi  Beta 
Pi  professional-social-medical  fraternity.  He 
was  presented  the  Award  on  July  13  by  Dr. 
Robert  C.  Berson,  dean  of  the  Medical  Col- 
lege. 


DR.  FINN  LECTURES  IN  BRAZIL 

Dr.  Sidney  B.  Finn,  professor  of  dentistry 
in  the  division  of  restorative  and  prosthetic 
dentistry,  has  been  at  the  Dental  School  of 
the  University  of  Brazil  in  Rio  de  Janeiro 
since  July  4 as  visiting  professor  and  lecturer 
of  a six-week  course  in  pedodontics,  attended 
by  teaching  personnel  from  various  dental 
schools  in  Brazil.  The  postgraduate  lecture 
series  is  being  conducted  under  the  auspices 
of  the  Brazilian  Association  of  Dental  Educa- 
tion, and  under  the  sponsorship  of  three 
groups:  the  W.  K.  Kellogg  Foundation,  ABE 
NO  (Associacao  Brasileira  de  Ensino  Odonto- 
logico),  and  CAPES  (a  Brazilian  governmen- 
tal agency  designed  to  improve  higher  edu- 
cation in  Brazil) . 

The  group  attending  the  course  has  been 
limited  in  number  to  10  professors  with 
enough  comprehension  of  English  to  under- 
stand the  lectures  without  need  of  a transla- 
tor. In  January  and  February  of  1961,  Dr. 
Finn’s  lectures  will  be  repeated  in  Portu- 
guese to  a larger  number  of  Brazilian  profes- 
sors. 

Before  beginning  his  visiting  professorship, 
Dr.  Finn  attended  the  meeting  of  the  dele- 
gates of  ABENO  in  Diamantina  in  the  Bra- 
zilian state  of  Minas  Geraes,  July  3.  Upon 
the  close  of  his  six-week  lecture  series,  Dr. 
Finn  will  spend  four  days  touring  various 
dental  schools  in  Sao  Paulo  and  other  sectors 
of  Brazil.  His  trip  will  also  include  visits  to 
Argentina  and  Uruguay.  He  will  be  in  Monte- 
video, Uruguay,  from  August  17-20,  and  in 
Buenos  Aires,  Argentina,  from  August  20-24. 

193 


STATE  DEFARTMENT  OF  HEALTH 


BUREAU  OF  ADMINISTRATION 

D.  G.  Gill,  M.  D. 

State  Health  Officer 


Follow-Up  Services  For 
The  Mentally  III  And  Their  Families 


A patient  who  is  discharged  from  a mental 
hospital  generally  needs  continued  care  and 
supervision  for  an  indefinite  period  after  his 
release.  During  his  hospitalization  his  fami- 
ly may  be  in  need  of  and  receptive  to  help 
from  a professionally  trained  person  who  can 
relieve  their  fears,  clear  up  misunderstand- 
ings, and  give  hope  for  the  patient’s  recovery 
and  help  in  planning  for  his  return  home. 

The  realization  that  such  services  were  not 
usually  available  led  to  the  development  of 
the  follow-up  program  for  mentally  ill  pa- 
tients and  their  families.  The  key  person  in 
this  program  is  the  public  health  nurse. 

The  program  was  developed  by  agreement 
between  the  Alabama  State  Hospitals  and  the 
State  Health  Department.  Before  this  agree- 
ment there  was  no  plan  for  follow-up  of  the 
mentally  ill  and  their  families.  A few  pa- 
tients with  means  could  secure  private  psy- 
chiatric treatment.  A few  could  be  served 
by  the  psychiatric  clinic  in  Birmingham  or 
by  the  County  Health  Department  Mental 
Health  Centers.  Some  undoubtedly  returned 
to  the  care  of  their  private  physicians.  Many, 
however,  were  without  supervision;  and 
there  were  few  if  any  sources  from  which 
their  families  could  seek  help. 


During  the  planning  sessions  which  led  to 
the  program,  it  was  brought  out  by  the  hos- 
pital staff  that  they  often  did  not  see  a mem- 
ber of  the  patient’s  family  for  some  time 
after  the  patient’s  admission  to  the  hospital. 
Occasionally,  they  never  saw  members  of  the 
family.  As  a consequence,  information  need- 
ed to  plan  for  the  patient’s  treatment  and  re- 
habilitation was  not  available  to  the  hospital 
staff.  Released  patients  were  often  returned 
to  the  hospital  because  their  families  lacked 
understanding  of  their  behavior  and  did  not 
want  them  at  home. 

It  was  apparent,  therefore,  that  the  public 
health  nurse  could  provide  a service  to  psy- 
chiatric patients  which  was  not  available 
from  any  other  source.  She  could  help  fami- 
ly membei’s  to  accept  and  adjust  to  the  pa- 
tient’s illness,  to  assume  their  responsibility 
for  his  recovery,  and  to  accept  him  as  a val- 
ued family  member  on  his  return  home.  She 
could  furnish  the  hospital  staff  with  pertinent 
information  about  the  family  situation,  their 
attitudes  toward  the  patient,  etc.  Through 
her  contacts  with  individuals  and  agencies  in 
the  community  she  could  seek  to  increase 
public  understanding  of  mental  illness.  When 
the  patient  returned  home  she  could,  under 


194 


J.  M.  A.  ALABAMA 


DEPARTMENT  OF  HEALTH 


the  direction  of  his  physician,  supervise  his 
care  and  cooperate  with  rehabilitation  work- 
ers and  others  interested  in  the  patient’s  well- 
being. 

This  program,  which  has  as  its  ultimate  ob- 
jective a reduction  in  the  readmission  rate 
to  the  State  Hospitals,  was  first  put  into  op- 
eration in  Etowah,  Jefferson,  and  Tuscaloosa 
counties.  It  has  since  been  extended  to  in- 
clude 28  more  counties  and,  hopefully,  will 
eventually  include  all  counties  in  the  state. 
In  these  counties,  the  local  health  department 
is  notified  when  a person  is  committed  to  the 
State  Hospital.  As  soon  as  possible  after  re- 
ceipt of  the  commitment  notice,  a public 
health  nurse  calls  on  the  family  to  determine 
if  they  need  and  want  the  services  she  is 
prepared  to  offer.  If  the  family  wishes  to 
accept  her  help,  she  continues  to  offer  help 
with  health  and  other  social  problems 
throughout  the  period  of  hospitalization. 
When  the  patient  is  discharged,  she  contin- 
ues to  work  with  the  family  and  other  com- 
munity agencies  for  as  long  as  is  necessary. 

An  in-service  training  program  has  been 
developed  for  the  nurses  who  work  in  this 
program.  The  training  program  is  coordi- 
nated by  the  Division  of  Mental  Hygiene, 
State  Health  Department.  The  public  health 
nurses  visit  the  hospital  to  acquire  an  under- 
standing of  commitment,  admission,  and  dis- 
charge procedures.  A series  of  conferences 
on  psychiatric  nursing  are  presented  to 
groups  of  nurses  throughout  the  state.  Case 
presentations  are  used  as  the  nucleus  for  dis- 
cussion and  instruction  in  concepts  and  prin- 
ciples of  psychiatric  nursing  care. 

What  the  program  can  mean  to  an  individ- 
ual and  his  family  is  illustrated  by  this  ac- 
count of  an  actual  case:  A 48  year  old  father 
of  five  children  was  committed  to  Bryce  Hos- 
pital as  an  emergency.  (The  fact  that  he 
was  acutely  mentally  ill  was  discovered  when 
he  sought  medical  care  for  hernia.)  When 
the  public  health  nurse  called  on  his  family, 
she  found  that  they  had  no  understanding  of 
mental  illness.  They  were  extremely  fright- 
ened, particularly  the  wife  who  was  afraid 
the  patient  would  blame  her  for  his  commit- 


ment. After  a few  visits  from  the  nurse, 
during  which  there  was  much  discussion  and 
explanation  of  the  father’s  illness,  the  wife 
came  to  see  that  she  had  acted  in  the  best  in- 
terests of  her  husband,  her  family,  and  the 
community.  Her  way  of  expressing  it:  “Why, 
it  was  the  least  I could  do  for  him.  Now  he 
can  get  well.  I hope  he’d  do  the  same  for 
me.”  She  decided  to  visit  her  husband  regu- 
larly while  he  was  hospitalized. 

The  patient  responded  to  treatment  and 
was  discharged  in  two  months.  He  and  his 
family  were  happy  to  be  together  again,  but 
the  neighbors  resented  his  return  because 
they  were  afraid  of  him.  They  complained 
to  the  rental  agency;  and,  as  a result,  the  fam- 
ily was  ordered  to  move.  The  public  health 
nurse  called  on  the  owner  of  the  property.  He 
was  aware  that  the  family  was  being  evicted 
but  thought  it  was  because  the  premises  were 
dirty  and  neglected.  When  he  realized  what 
was  happening,  he  called  the  real  estate  agent 
and  explained  the  family’s  predicament.  The 
nurse  also  visited  the  agent  and  the  neigh- 
bors. She  explained  what  their  actions  were 
doing  to  the  recently  discharged  patient  and 
his  family.  (The  patient  was  beginning  to 
show  signs  of  nervousness,  and  the  wife  was 
almost  in  a state  of  collapse.)  The  visits  of 
the  nurse  seemed  to  help  these  people  acquire 
some  understanding — or  at  least  tolerance — 
of  mental  illness.  At  any  rate,  the  real  estate 
agent  stopped  the  eviction  proceedings  and 
called  on  the  family  and  apologized  to  them. 
Gradually,  the  neighbors  began  to  be  friend- 
ly with  the  family  and  to  make  them  feel 
welcome  in  the  community. 

And  so,  this  family,  with  the  help  of  the 
nurse,  has  weathered  a crisis  which  could 
have  meant  the  patient’s  return  to  the  hos- 
pital. He  is  now  on  the  road  to  complete  re- 
covery and  with  continued  help  and  under- 
standing should  be  able  to  re-assume  com- 
plete responsibility  for  his  family  in  the  fu- 
ture. 


SEPTEMBER  I960— VOL.  30.  NO.  3 


195 


DEPARTMENT  OF  HEALTH 


BUREAU  OF  PREVENTABLE  DISEASES 
W.  H.  Y.  Smith,  M.  D.,  Director 
CURRENT  MORBIDITY  STATISTICS 
1960 

“E.  E. 

June  July  July 


Typhoid  and  paratyphoid 

2 

5 

4 

Undulant  fever  . 

2 

3 

1 

Meningitis  

5 

3 

9 

Scarlet  fever  

37 

29 

21 

Whooping  cough 

5 

21 

48 

Diphtheria  

1 

0 

4 

Tetanus  

1 

0 

4 

Tuberculosis  

104 

162 

191 

Tularemia  ..  

0 

0 

0 

Amebic  dysentery 

9 

9 

1 

Malaria  

0 

1 

1 

Influenza  — 

28 

22 

35 

Smallpox  ..  

0 

0 

0 

Measles  . 

362 

89 

172 

Poliomyelitis  

0 

7 

57 

Encephalitis  

5 

1 

1 

Chickenpox  

150 

26 

17 

Typhus  fever..  ..  .. 

2 

0 

1 

Mumps  

53 

36 

46 

Cancer  

406 

655 

475 

Pellagra  ...  

0 

0 

0 

Pneumonia  

164 

167 

85 

Syphilis  

157 

145 

155 

Chancroid  . 

4 

2 

3 

Gonorrhea  

296 

303 

323 

Rabies — Human  cases 

0 

0 

0 

Pos.  animal  heads 

5 

3 

0 

As  reported  by  physicians  and 

including 

deaths  not 

re- 

ported  as  cases. 

•E.  E. — The  estimated  expectancy  represents  the  median 
incidence  of  the  past  nine  years. 

.it 

BUREAU  OF  LABORATORIES 

Thomas  S.  Hosty,  Ph.D.,  Director 

SPECIMENS  EXAMINED 
July  19S0 


Examinations  for  malaria 47 

Examinations  for  diphtheria  bacilli 

and  Vincent’s 24 

Agglutination  tests  535 

Typhoid  cultures  (blood,  feces  and  urine)  . 483 

Brucella  cultures ...  7 

Examinations  for  intestinal  parasites  3,027 

Darkfield  examinations  . . 2 

Serologic  tests  for  syphilis  (blood  and 

spinal  fluid)  25,508 

Examinations  for  gonococci 1,883 

Complement  fixation  tests  . ..  . 133 

Examinations  for  tubercle  bacilli  ..  3,319 

Examinations  for  Negri  bodies  ( smears 

and  animal  inoculations)  . 210 

Water  examinations ..  3,156 

Milk  and  dairy  products  examinations  4,236 

Miscellaneous  examinations  2,609 


Total 45,179* 


*This  includes  a total  of  3,949  specimens  exam- 
ined by  the  Mobile  Branch  Laboratory  during 
June,  such  report  not  being  received  in  time  to 
include  in  June  report. 


BUREAU  OF  VITAL  STATISTICS 

Ralph  W.  Roberts,  M.  S„  Director 


PROVISIONAL  BIRTH  AND  DEATH 
STATISTICS,  AND  COMPARATIVE  DATA, 
MAY  1960 


Live  Births 
Deaths 

Causes  of  Death 

Number 

Registered 

During 

Rates* 

(Annual  Basis) 

1 

' Total 

o 

2 

5 

c 

Non- 

White 

1960 

1959 

1958 

Live  births 

5,977 

3,793i  2,184 

21,7 

22.0 

21.8 

Deaths  

2,531 

1,619 

912 

9.2 

8.3 

8.3 

Fetal  deaths  

137 

67 

70 

22.4 

20.0 

23.9 

Infant  deaths — 

under  one  month 

143 

88 

55 

23.9 

23.7 

26.9 

under  one  year _.. 

204 

111 

93 

35.8 

32.0 

38.1 

Maternal  Deaths  

7 

2 

5 

11.4 

8.1 

3,3 

Cause  of  Death 

Tuberculosis,  001-019 

22 

8 

14 

8.0 

5.5 

11.4 

Syphilis,  020-029  

4 

4 

1 4 

4 0 

3.0 

Dysentery,  045-048  



0.7 

Diphtheria,  055 



Whooping  cough,  056 

2 

1 

1 

0.7 

0,7 

Meningococcal  infec- 

fections,  057  

1 

1 

0.4 

0 4 

Poliomyelitis,  080,  081 

0.4 

Measles,  085  

3 

2 

1 

1.1 

0,7 

1.5 

Malignant  neo- 

plasms,  140-205 

314 

222 

92 

113.8 

115.4 

99.2 

Diabetes  mellitus,  260 

43 

23 

20 

15.6 

8.0 

11.8 

Pellagra,  281  . 

0.4 

Vascular  lesions  of 

central  nervous 

system,  330-334 

342 

215 

127 

123.9 

116.1 

126.1 

Rheumatic  fever. 

400-402 

5 

3 

2 

1.8 

Diseases  of  the 

heart,  410-443  

876 

596 

280 

317.4 

271.3 

272.6 

Hypertension  with 

heart  disease,  440-443 

171 

44 

97 

62.0 

49.3 

51.6 

Diseases  of  the 

arteries,  450-456  

49 

34 

15 

17.8 

19.7 

14.8 

Influenza,  480-483 

11 

8 

3 

4.0 

2.2 

5.2 

Pneumonia,  all  forms. 

490-493  ... 

73 

45 

28 

26.4 

19.4 

19.5 

Bronchitis,  500-502  

10 

8 

2 

3.6 

2.2 

0.7 

Appendicitis,  550-553 

3 

2 

1 

1.1 

1.1 

1.0 

Intestinal  obstruction 

and  hernia,  560, 

561,  570 

13 

9 

4 

4.7 

4.0 

3.3 

Gastro-enteritis  and 

colitis,  under  2,  571.0, 

764  . .. 

6 

3 

3 

2,2 

2.2 

1.8 

Cirrhosis  of  liver,  581 

17 

14 

3 

6.2 

6.2 

5.9 

Diseases  of  pregnancy 

and  childbirth,  640-689 

7 

2 

5 

11.4 

8.1 

3.3 

Congenital  malforma- 

tions,  750-759 

27 

25 

2 

4.5 

3.8 

4,6 

Immaturity  at  birth. 

774-776  

50 

27 

23 

8.4 

9.1 

8.6 

Accidents,  total,  800-962 

174 

117 

57 

63.0 

70.8 

57.2 

Motor  vehicle  acci- 

dents,  810-835,  960 

99 

73 

26 

35.9 

35.8 

28.8 

All  other  defined 

causes  

366 

209 

157 

132.6 

120.8 

128.0 

Ill-defined  and  un- 

known  causes. 

780-793,  795 

113 

45 

68 

40.9 

27.7 

35.8 

*Rates:  Birth  and  death — per  1.000  population 
Infant  deaths — per  1.000  live  births 
Fetal  deaths — per  1.000  deliveries 
Maternal  deaths — per  10,000  deliveries 
Deaths  from  specified  causes — per  100,000  population 


196 


J.  M.  A.  ALABAMA 


THE  JOURNAL 

of 

THE  MEDICAL  ASSOCIATION  OF  THE  STATE  OF  ALABAMA 

Published  Under  the  Auspices  of  the  Board  of  Censors 
Vol.  30  October  1960  No.  4 


Hypothermia  In  The  Management 
Of  Brain  Injuries 


J.  GARBER  GALBRAITH,  M.  D. 


Birmingham,  Alabama 


The  severe  morbidity,  disabling  sequelae 
and  mortality  following  acute  brain  trauma 
are  usually  the  result  of  fulminating  cerebral 
edema  or  intracranial  hemorrhage.  Trau- 
matic intracranial  hemorrhage,  epidural  or 
subdural,  is  easily  recognized  clinically  and  is 
amenable  to  surgical  management  with  grati- 
fying results  in  the  great  majority  of  cases. 
However,  it  is  only  the  occasional  case  that  is 
amenable  to  surgical  relief;  most  brain  in- 
juries sustained  in  vehicular  accidents  result 


Dr.  Galbraith  is  a graduate  of  the  Medical  Col- 
lege of  St.  Louis  University  and  a Fellow  of  the 
American  College  of  Surgeons.  He  is  a professor 
of  surgery  and  director  of  the  Section  on  Neuro- 
surgery of  the  Medical  College  of  Alabama.  He  is 
this  year’s  president  of  the  Jefferson  County  Medi- 
cal Society. 

Presented  at  the  annual  session  of  the  Associa- 
tion, April  21,  1960,  Mobile,  Alabama. 


in  generalized  cerebral  contusion  and  swell- 
ing. It  is  in  the  management  of  this  larger 
group  of  the  seriously  injured  that  treatment 
has  too  often  proven  ineffectual. 

Pathological  Physiology  of  Brain  Injury 

Aside  from  the  actual  destruction  of  neural 
tissue,  the  cellular  reaction  is  one  of  increased 
metabolic  activity  with  greater  oxygen  re- 
quirement. There  is  increased  permeability 
of  the  cell  membrane  with  loss  of  potassium 
and  retention  of  sodium.  The  vascular  re- 
action is  one  of  capillary  vasodilatation  with 
stasis  and  hyperpermeability  resulting  in  lo- 
cal anoxia  and  fluid  loss  into  the  tissues.  The 
resulting  edema  produces  brain  swelling, 
lateral  shift  of  the  cerebral  hemisphere  with 
tentorial  herniation,  aqueductal  obstruction 
and  brain  stem  compression.  This  ultimately 
determines  the  fatal  outcome. 


BRAIN  INJURIES 


Clinical  Course 

In  severe  brain  injury  there  is  immediate 
loss  of  consciousness  with  accompanying  abo- 
lition of  cough  and  swallowing  reflexes.  This 
results  in  tracheobronchial  aspiration  of  blood 
and  vomitus  in  transit  to  the  hospital.  The 
patient  becomes  febrile  with  rapid,  labored 
respiration  and  rapid  pulse  rate.  Fever  in- 
creases the  cerebral  metabolic  activity  while 
aspiration  pneumonitis  reduces  the  oxygen 
supply  to  the  brain.  These  changes  aggravate 
the  cerebral  swelling  producing  deepening 
coma  and  a progressive  deterioration  in  the 
clinical  picture.  Such  a situation  often  pro- 
gresses to  a fatal  outcome  in  forty-eight  to 
seventy-two  hours. 


Management 

Obviously,  the  immediate  effects  of  the 
trauma  cannot  be  overcome.  The  goal  of 
treatment  then  should  be  the  prevention  of 
the  progressive  changes  described  above 
which,  in  the  natural  course  of  events,  follow 
a severe  brain  injury.  Establishment  and 
maintenance  of  a mechanically  clear  airway 
cannot  be  over-emphasized.  Tracheostomy 
continues  to  be  a most  valuable  and  often 
life-saving  procedure,  especially  when  there 
has  been  a time  lag  in  instituting  treatment. 

On  admission,  with  evidence  of  severe  brain 
injury  manifested  by  coma,  additional  meas- 
ures may  be  required,  especially  if  there  is 
evidence  of  brain  stem  involvement.  Rising 
temperature,  convulsions,  decerebrate  rigid- 
ity and  alterations  of  the  vital  signs,  consti- 
tute the  indications  for  more  vigorous  treat- 
ment. It  goes  without  saying  that  if,  at 
any  time,  localizing  signs  develop,  surgi- 
cal measures  are  instituted  without  delay. 
Agents  for  reduction  of  brain  swelling  have 
generally  been  found  wanting.  There  is,  un- 
fortunately, a delayed  rebound  reaction  to 
most  dehydrating  agents,  although  urea  may 
at  times  prove  life-saving  by  its  temporary 
beneficial  effect. 


Hypothermia 

It  is  in  this  group  of  gravely  injured  cases 
with  poor  prognosis  that  hypothermia  has  re- 
cently proven  helpful.  Experimental  studies 
had  previously  demonstrated  that  hypo- 
thermia reduces  cerebral  metabolic  activity, 
(oxygen  requirement  is  reduced  50%  at  30° 
Centigrade),  and  reduces  cerebral  blood  flow 
and  volume.  It  also  decreases  brain  volume 
and  intracranial  pressure.  Thus,  both  the 
primary  (cellular)  and  secondary  (edema) 
components  of  brain  injury  may  be  modified 
by  this  method.  In  experimental  animals  un- 
der hypothermia  at  25°  Centigrade,  traumatic- 
brain  lesions  which  were  uniformly  fatal  to 
normothermic  control  animals  produced  only 
moderate  local  reaction  with  ultimate  re- 
covery and  with  only  mild  reactive  gliosis. 
Survival  and  function  at  a lower  metabolic 
level  may  continue  within  areas  rendered 
anoxic  or  ischemic  by  edema  or  vascular  in- 
sufficiency. It  thus  follows  that  shock  is  not 
a contraindication  to  hypothermia. 


Methods  of  Cooling 

Cooling  can  be  achieved  by  any  convenient 
method.  An  inverted  plastic  mattress  cover 
wrapped  about  the  patient  can  be  filled  with 
crushed  ice.  Ice  bags  and  a water  mattress  ir- 
rigated with  ice  water  are  not  as  efficient  but 
make  nursing  care  simpler.  The  “Thermorite” 
apparatus  which  is  used  at  the  University 
Hospital  for  induction  of  rapid  and  maximum 
hypothermia  for  cardiac  and  intracranial  vas- 
cular surgery,  represents  the  ultimate  in 
equipment  at  the  present  time.  Constant 
temperature  recording  is  by  a rectal  thermo- 
couple devised  by  Dr.  Leland  Clark  of  the 
Vascular  Surgery  Unit.  In  the  comatose  pa- 
tient no  anesthesia  is  required  for  induction 
of  hypothermia,  but  thorazine®  or  sparine® 
must  be  administered  in  dosage  adequate  to 
control  shivering  during  the  induction.  Car- 
diac irregularities  and  possible  ventricular 
fibrillation  must  be  carefully  watched  for 
during  induction,  and  adequate  facilities 


198 


J.  M.  A.  ALABAMA 


BRAIN  INJURIES 


should  be  available  for  correction  of  these 
potential  complications.  The  clinical  response 
is  one  of  a general  reduction  of  motor  activity, 
relaxation  of  spasticity  or  decerebrate  rigid- 
ity, and  a gradual  fall  in  pulse,  blood  pressure 
and  cardiac  output.  Respiration  is  reduced  to 
a basal  level.  The  pupils  become  constricted. 
The  effective  range  of  hypothermia  in  the 
severely  injured  is  90°  to  92°  Fahrenheit.  Hy- 
pothermia is  maintained  for  a period  of  eigh- 
teen to  twenty-four  hours  after  which  time 
gradual  re-warming  is  begun.  Close  obser- 
vation is  then  necessary  to  detect  any  re-ap- 
pearance  of  unfavorable  neurological  signs 
which  might  indicate  the  need  for  re-institu- 
tion  of  the  cooling  process.  This  is  thus  con- 
tinued from  day  to  day  until  such  time  as 
re-warming  can  be  accomplished  with  no  un- 
favorable developments. 

It  must  be  emphasized  that  signs  of  pro- 
gressive cerebral  compression  due  to  intra- 
cranial bleeding  may  be  somewhat  obscured 
by  hypothermia.  Therefore,  careful  evalua- 
tion of  the  neurological  status  must  be  con- 
tinued lest  the  need  for  surgical  intervention 
develop  and  fail  to  be  recognized. 

One  point  in  particular  which  requires  fur- 
ther experience  is  the  selection  of  cases  for 


this  method,  and  in  the  near  future  we  should 
have  more  definite  criteria  in  this  regard.  It 
is  further  anticipated  that  hypothermia  may 
well  have  a place  in  the  management  of  other 
types  of  cerebral  lesions  such  as  infarction 
and  spontaneous  intracerebral  hemorrhage  as 
well  as  its  already  proven  invaluable  place 
as  an  adjunct  to  the  surgical  management  of 
intracranial  aneurysms. 


Conclusion 

An  insufficient  number  of  cases  and  neces- 
sarily short  follow-up  preclude  any  conclu- 
sions concerning  the  value  of  hypothermia  at 
the  present  time.  Furthermore,  the  equip- 
ment required  and,  particularly,  the  trained 
personnel  needed  to  administer  the  method 
constitute  a limitation  of  its  usefulness.  How- 
ever, we  have  gained  the  distinct  impression 
that  this  method  has  proved  life-saving  in 
cases  of  severe  brain  injury  of  the  type  de- 
scribed which  would  otherwise  have  pro- 
gressed rapidly  to  fatal  outcome.  This  is  par- 
ticularly true  in  the  childhood  and  young 
adult  age  group. 


!9^ 


OCTOBER  I960— VOL.  30,  NO.  4 


Emotional  Problems  In  Pediatrics 


HUGHES  KENNEDY.  JR..  M.  D. 


Birmingham.  Alabama 


I am  quite  sure  a higher  and  higher  per- 
centage of  my  time  is  being  devoted  to  dis- 
cussing emotional  disturbances  affecting  eith- 
er the  patient,  the  family,  or  both.  Since  I 
am  sure  that  you  are  having  the  same  prob- 
lems, I thought  it  might  be  of  mutual  benefit 
to  discuss  them  with  you.  Since  there  ap- 
pears to  be  no  ready  solution  to  these  prob- 
lems, our  chief  hope  lies  in  frequent  discus- 
sions in  an  attempt  to  arrive  at  the  etiology. 
As  so  frequently  happens,  discovery  of  the 
etiology  might  reveal  the  solution.  I am  a 
pediatrician  and  not  a trained  psychologist 
nor  psychiatrist;  therefore,  it  is  not  my  inten- 
tion to  lead  you  through  the  intricacies  of 
psychiatric  procedures.  Rather,  it  is  my  pur- 
pose to  discuss  with  you  behavior  problems 
instead  of  psychiatric  patients,  with  the  reali- 
zation that  if  the  behavior  problem  is  not 
correctly  handled,  the  child  may  progress  to 
the  need  of  real  psychiatric  care. 

Immediately  after  birth  the  parents  tend 
to  compare  their  new  baby  with  other  babies 
in  their  acquaintance.  They  want  him  to 
eat,  sleep,  and  stool  like  other  babies,  but,  at 


Dr.  Kennedy  is  a graduate  of  Harvard  University 
Medical  School,  a member  of  the  American  Acad- 
emy of  Pediatrics,  and  an  associate  professor  of 
pediatrics  at  the  Medical  College  of  Alabama. 

Presented  at  the  19th  post  graduate  seminar  of 
the  Alabama  Academy  of  General  Practice,  August 
20,  1959,  Birmingham,  Alabama. 


the  same  time,  they  want  him  to  be  superior 
to  other  children.  They  want  him  to  grow 
fast,  to  be  fat,  and  to  be  extra  smart.  They 
are  not  satisfied  with  average.  They  want 
to  play  with  their  new  offspring  at  their  con- 
venience and  then  cannot  understand  why 
the  baby  does  not  sleep  when  they  choose 
quiet  and  peace.  They  do  not  seem  to  realize 
that  the  baby  comes  into  the  world  without 
any  habits.  It  is  human  nature  to  develop 
habits,  and  child  training  is  nothing  more 
than  directing  the  baby  along  a proper  course 
so  that  he  will  be  a pleasure  to  himself  as  well 
as  to  others.  I do  not  like  the  term  “spoiled 
baby”.  I much  prefer  to  call  such  a child  im- 
properly trained. 

The  pediatrician  sees  the  baby  as  a healthy, 
happy  addition  to  the  family.  With  proper 
care  and  attention  he  should  grow  and  de- 
velop into  a useful  citizen. 

Preparation  should  begin  with  the  obste- 
trician. He  should  prepare  the  prospective 
parents  for  their  responsibilities,  even  as  the 
minister  has  prepared  them  for  marriage.  To- 
day there  are  so  many  social  and  civic  activi- 
ties going  on  that  young  couples  soon  find 
themselves  engulfed  in  the  merry  whirl. 
When  the  new  baby  arrives,  a monkey- 
wrench  seems  to  have  been  thrown  into  the 
machinery.  Since  maids  are  difficult  or  im- 
possible to  obtain  and  finance,  the  parents 
find  a severe  curb  on  their  social  functions. 


200 


J.  M.  A.  ALABAMA 


EMOTIONAL  PROBLEMS  IN  PEDIATRICS 


They  are  under  constant  tension  in  their  de- 
sire to  take  good  care  of  the  baby  and,  at  the 
same  time,  maintain  their  other  activities.  I 
believe  that  proper  prenatal  care  should  in- 
clude preparation  of  the  parents  for  what  is 
to  come. 

The  first  three  months  of  a baby’s  life  are 
all  important.  This  is  the  period  when  the 
baby  should  sleep  and  eat.  If  he  is  allowed 
these  privileges  without  the  disturbances  of 
being  put  on  exhibition  and  handled  exces- 
sively, he  will  arrive  at  the  age  when  he  will 
enjoy  personal  attention  when  it  is  given  him 
but  will  not  demand  it  when  it  cannot  be 
given.  The  family  can  remain  calm  and 
composed  more  easily  if  they  set  proper 
standards. 

This  does  not  mean  that  I think  babies 
should  have  no  personal  attention.  They  do 
need  affection  and  loving  care.  I insist  that 
they  be  held  while  being  fed,  never  propping 
the  bottle  in  the  mouth.  The  baby  will  re- 
ceive adequate  handling  and  personal  atten- 
tion during  the  feeding  and  bath  periods.  A 
number  of  years  ago  Dr.  Robert  Strong,  Pro- 
fessor of  Pediatrics  at  Tulane,  did  some  in- 
vestigative work  at  a foundling  home.  He 
demonstrated  definitely  that  babies  held 
while  being  fed  gained  more  rapidly  than 
those  with  a propped  bottle,  although  the 
caloric  intake  was  the  same  in  each  group. 
When  he  switched  the  group,  i.e.,  when  the 
propped-bottle  group  was  held,  these  babies 
began  growing  faster  than  the  group  which 
was  no  longer  being  held. 

In  “Babies  are  Human  Beings”,  Aldrich 
states  that  each  baby  comes  into  the  world 
with  a predetermined  physique.  God  above 
is  the  architect,  and  only  He  knows  what  the 
finished  product  will  be.  The  parents  are  the 
contractors,  and  they  have  the  privilege  of 
furnishing  the  material  for  growth,  both  phys- 
ical and  mental.  While  the  final  stature  of 
the  child  cannot  be  appreciably  altered,  as 
long  as  proper  food  is  given,  the  mental  and 
cultural  side  of  the  child’s  life  is  much  influ- 
enced by  home  care. 

In  infant  and  child  care  and  training  it  is 
most  important  to  set  proper  standards.  A 


Shetland  pony  borns  a Shetland  colt.  The 
American  race,  however,  is  not  a pure  breed 
but  an  admixture  of  many  different  nationali- 
ties and  many  different  physiques.  Therefore, 
we  must  realize  the  fact,  as  stated  by  Aldrich, 
that  we  will  not  know  what  the  finished  prod- 
uct will  be.  One  of  the  joys  of  child  care 
should  be  the  flowering  of  the  child’s  physique 
and  character.  One  child  will  teethe  early, 
another  will  crawl  early,  another  will  sit  or 
talk  earlier  than  other  children;  but  when 
the  school  bell  rings  for  them  at  the  age  of 
six  years,  the  vast  majority  will  be  average, 
normal,  healthy  children,  and  ready  to  enter 
school.  It  is  the  problem  of  the  physician 
to  see  that  this  physically  average  child  is 
also  mentally  and  psychologically  sound,  and 
ready  to  enter  an  important  new  phase  of  his 
life. 

These  worries  on  the  part  of  the  parents  are 
accentuated  by  numerous  articles  and  lay 
publications  which  fail  to  state  that  the  writer 
is  discussing  the  average,  and  even  in  some 
instances,  superior  children.  They  do  not 
give  the  normal  variations.  When  the  child 
under  discussion  does  not  measure  up  to  the 
published  standards,  the  parents  are  much 
concerned;  although,  in  reality,  they  may 
have  a perfectly  normal  baby.  On  one  oc- 
casion, a mother  called  me  in  great  distress, 
stating  that  her  young  infant  had  slept  only 
twenty-one  hours  out  of  the  past  twenty-four, 
while  a book  in  her  hand  stated  that  he  should 
have  slept  twenty-two  hours.  As  I report 
this  incident  to  you,  it  sounds  rather  ridicu- 
lous; but  to  this  perfectly  intelligent  mother, 
it  was  rather  a serious  defect  that  she  had 
found  in  her  baby. 

When  I see  a baby  for  the  first  time,  I try 
to  get  it  across  to  the  mother  that  we  are  go- 
ing to  offer  the  baby  all  the  food  that  he 
wishes  and  let  him  decide  the  final  amount. 
Barring  any  disease  on  the  part  of  the  baby, 
this  has  many  times  been  proven  to  be  a safe 
procedure.  It  is  extremely  rare  for  a baby  to 
take  too  much.  If  he  should  take  too  much,  he 
will  probably  spit  up  the  excess,  but  will  not 
be  made  ill.  When  the  baby  seems  to  take 
too  little,  you  cannot  force  him,  although  this 
is  constantly  tried.  Eventually,  the  mother  of 


OCTOBER  I960— VOL.  30,  NO.  4 


201 


EMOTIONAL  PROBLEMS  IN  PEDIATRICS 


the  small  eater  will  complain  that  her  baby 
is  not  growing  as  fast  as  the  child  next  door 
and  that  she  cannot  get  enough  food  into  him. 
When  you  tell  her  that  she  should  quit  trying 
to  force  him,  she  will  readily  admit  that  forc- 
ing does  no  good  and  that  she  has  never  suc- 
ceeded in  the  slightest.  Although  you  try 
diligently  to  assure  her  that  the  baby  will 
take  all  that  he  actually  needs,  and  that  his 
growth  will  continue  along  nature’s  plotted 
design,  and  although  you  feel  that  you  have 
gotten  your  point  across,  she  is  very  likely  to 
come  back  with  “but  Doctor,  the  baby  is  not 
growing  as  fast  as  I would  like  for  him  to  do”. 
It  is  this  sonic  barrier  of  parental  education 
that  you  and  I must  penetrate  and  succeed 
in  convincing  the  family  that  children  do 
vary.  Would  it  not  be  a very  drab  world  if 
every  baby  came  into  the  world  exactly  the 
same  height  and  weight,  developed  exactly 
the  same  and  grew  into  adult  life  wearing 
the  same  size  clothes?  It  is  your  task  and 
my  task  to  prevent  these  false  standards  from 
developing. 

If  we  do  not  succeed  in  preventing  prob- 
lems from  developing,  we  must  be  ready  to 
correct  them  when  they  do  occur. 

We  see  many  more  cases  of  colic  today  than 
formerly.  So-called  colic  seems  to  develop 
regardless  of  what  the  young  infant  is  being 
fed.  Although  the  baby  is  doing  well  in  the 
hospital  nursery,  (they  never  have  colic  in 
the  hospital) , it  is  rare  that  the  family  does 
not  call  within  twenty-four  to  forty-eight 
hours  that  the  baby  is  not  getting  enough 
food,  or  else  that  it  is  causing  colic.  This 
seems  to  occur  whether  the  baby  is  on  a 
self-demand  feeding  schedule  or  on  regular 
hours,  whether  he  is  on  the  breast  or  a formu- 
la. In  many  of  these  cases  the  symptoms  are 
completely  relieved,  either  by  changing  the 
brand  of  evaporated  milk,  or  by  changing  the 
brand  of  powdered  milk,  which  you  will  re- 
alize is  really  not  changing  the  formula  in 
any  way.  However,  to  the  new  parent,  a ma- 
jor change  has  been  made,  and  success  is  our 
reward.  To  me,  this  is  ample  proof  that  the 
baby  has  really  not  been  suffering  from  genu- 
ine colic,  but  more  likely  from  tension  in  the 


family.  It  is  this  early  tension  which  causes 
many  babies  to  bo  taken  from  the  breast. 

The  brain  puts  out  enough  electricity  to 
register  on  an  electroencephalogram.  It  is  my 
belief  that  sufficient  electrical  waves  are  put 
out  by  members  of  the  family  to  disturb  the 
baby.  In  other  words,  it  is  important  for  the 
family  and  the  baby  to  be  tuned  together  on 
the  same  wave  length.  If  they  are  out  of 
tune,  baby’s  static,  or  colic  to  the  mother,  will 
develop.  The  fact  that  the  first  baby  in  the 
family  usually  has  more  colic  than  subsequent 
siblings  strengthens  this  hypothesis. 

On  one  occasion  I was  called  to  see  an  eight 
weeks  old  baby  on  Sunday  night  about  ten 
o’clock.  Over  the  phone,  the  mother  stated 
that  the  baby  had  been  crying  since  noon  the 
day  before  and  that  she  had  been  doing  this 
each  week  end  for  the  past  month.  She  re- 
minded me  that  the  maid  had  brought  the 
baby  in  the  previous  two  Mondays,  and  that  I 
had  been  unable  to  find  anything  wrong  with 
the  baby,  and  the  change  of  formula  had  had 
no  effect  on  the  crying.  She  urged  me  to 
come  over  and  examine  the  baby  during  one 
of  her  spells.  I purposely  delayed  my  call 
for  thirty  to  forty  minutes.  When  I walked 
down  the  hall  and  rang  the  bell  of  the  apart- 
ment, I heard  no  crying.  When  the  mother 
opened  the  door,  she  was  much  embarrassed, 
and  stated  that  the  baby  had  quit  crying 
about  ten  minutes  after  the  phone  call.  In 
fact,  she  had  called  my  home  to  cancel  the 
visit,  but  I had  just  driven  off.  After  awaken- 
ing and  thoroughly  examining  the  baby  to 
convince  the  mother  that  there  was  nothing 
physically  wrong,  I outlined  the  situation  as 
I saw  it.  The  background  was  this:  The 

mother  had  come  from  another  state  to  have 
her  illegitimate  baby  delivered.  The  baby  did 
well  during  the  first  month  when  the  mother 
stayed  at  home.  At  the  end  of  that  time,  she 
went  to  work,  leaving  her  baby  with  a maid. 
When  the  mother  arrived  home  at  noon  on 
Saturday,  the  maid  left  and  did  not  return 
until  Monday  morning.  Although  the  maid 
would  state  to  me  on  Monday  morning  that 
the  baby  was  a little  lamb  and  never  cried, 
the  mother  stated  that  the  week  end  crying 


202 


J.  M.  A.  ALABAMA 


EMOTIONAL  PROBLEMS  IN  PEDIATRICS 


was  terrific.  Certainly  I heard  the  baby  cry- 
ing over  the  phone  when  she  called  me. 
Therefore,  my  discussion  with  the  mother 
went  something  like  this:  “Your  baby  is  in 
excellent  physical  condition  and  has  been 
gaining  weight  most  satisfactorily.  When  you 
come  home  on  Saturday  at  noon,  you  are  tied 
down  until  Monday  morning  without  any 
form  of  pleasure  or  recreation.  Although  you 
are  most  devoted  to  your  baby,  you  feel  the 
restrictions  and  subconsciously  are  resentful 
that  you  cannot  go  out  freely  to  make  friends. 
When  you  called  me  an  hour  ago,  you  had 
such  faith  in  my  ability  to  find  the  cause  of 
her  crying  that  you  promptly  relaxed  and 
wondered  why  you  had  not  called  me  earlier. 
As  soon  as  you  relaxed,  you  quit  putting  out 
nervous  electrical  waves,  the  baby  experi- 
enced your  relaxation,  and  she  promptly  went 
to  sleep”.  I advised  her  to  employ  another 
maid  for  part  time  on  Saturday  afternoon  and 
Sunday  so  that  she  could  have  some  relaxa- 
tion and  pleasure.  Frankly,  I was  surprised 
and  pleased  at  the  readiness  with  which  she 
agreed  that  I was  right.  The  baby  slept  all 
night,  and  the  following  week  ends  were  quite 
happy  for  both  mother  and  child. 

I do  not  believe  that  this  explanation  is  too 
farfetched.  I have  seen  this  happen  too  often 
to  be  mere  coincidence. 

Another  mother  phoned  me  that  her  eight 
months  old  baby  was  staying  awake  each 
night  from  ten  p.m.  until  one  a.m.  She  was 
not  crying  and  was  perfectly  happy.  This  had 
happened  for  the  past  three  nights.  On  ques- 
tioning, I found  that  the  mother  had  gone  into 
the  baby’s  room  three  nights  before  to  see 
whether  the  baby  had  sufficient  cover.  When 
she  turned  on  the  light,  she  found  the  baby 
awake  but  perfectly  happy.  However,  she 
proceeded  to  sit  there  and  watch  the  baby 
until  she  went  back  to  sleep.  After  three 
such  nights,  she  called  for  advice.  I inquired 
of  the  mother  if  she  had  made  a habit  of  go- 
ing in  to  see  the  baby  every  night.  She  re- 
plied that  she  had  not  and  that  this  was  the 
first  time  she  had  been  in  for  quite  some  time. 
I then  suggested  that  maybe  the  baby  always 
stayed  awake  at  those  hours  at  night,  enjoy- 
ing the  communion  of  her  own  soul,  and  that 


maj'be  she  was  trespassing  on  the  babj^’s  time. 
I suggested  that  she  quit  going  in  to  see 
whether  the  baby  was  awake.  I was  hoping 
that  the  three  nightly  experiences  had  not 
taught  the  baby  to  expect  attention.  Later, 
the  mother  phoned  that  she  had  not  gone  in 
and  had  heard  nothing  from  the  baby.  In  this 
case  the  mother  was  about  to  get  into  some 
serious  trouble  but  was  stopped  in  time.  This 
case  is  one  of  many  that  have  indicated  to  me 
that  if  a baby  is  properly  trained  in  early  in- 
fancy, he  will  accept  pleasures  at  a later  time 
but  is  not  as  likely  to  demand  that  they  con- 
tinue. Had  this  been  a six  weeks  old  baby,  he 
might  have  cried  the  fourth  night  when  he 
was  unattended.  I throw  out  the  suggestion 
that  probably  these  reactions  of  the  very 
young  infant  are  conditioned  reflexes.  Ba- 
bies are  creatures  of  habit;  therefore,  start 
them  off  correctly. 

Although  babies  are  creatures  of  habit,  they 
do  have  likes  and  dislikes.  I have  seen  fret- 
ful babies  become  very  happy  when  taken  out 
of  a bassinet  and  put  on  a big  bed.  Fretful- 
ness would  recur  when  placed  back  in  the 
bassinet.  When  these  babies  are  put  perma- 
nently in  a large  baby  bed  with  open  sides, 
their  dispositions  are  changed  for  the  better. 
Could  they  be  victims  of  claustrophobia? 

A mother  of  a seventeen  months  old  baby 
has  just  informed  me  that  the  baby  remains 
up  until  ten  o’clock  each  night.  She  stated 
that  she  knew  she  was  doing  this  against  my 
advice,  but  she  and  her  husband  enjoyed  this 
time  with  the  baby  very  much  and  were  not 
willing  to  give  it  up.  She  also  realized  that 
she  would  probably  have  to  pay  the  piper  at 
a later  date.  It  will  probably  come  sooner 
than  she  thinks.  She  is  expecting  another 
baby  in  the  fall.  Can  you  not  anticipate  this 
baby’s  reaction  when  the  new  sibling  arrives 
and  he  ceases  to  be  the  entire  show? 

In  1932,  Brennemann’  presented  a paper  be- 
fore the  Philadelphia  Psychiatric  Society  en- 
titled, “Pediatric  Psychology  in  the  Child 
Guidance  Movement”.  He  stated  that  child 
behavior  problems  were  increasing  in  number 
on  account  of  family  tensions  and  because  the 
children  were  getting  too  much  personal  at- 

1.  Brennemann;  J.  Pediat.  2:  1,  January  ’33. 


OCTOBER  I960 — VOL.  30,  NO.  4 


203 


EMOTIONAL  PROBLEMS  IN  PEDIATRICS 


lenlion.  He  further  staled  that  any  child  that 
did  not  react  with  vigor  against  an  unfavor- 
able situation  was  a dud.  I am  sure  that  the 
above  seventeen  months  old  baby  is  not  a 
dud  and  that  he  will  react  boisterously  when 
the  new  sibling  arrives.  He  will  resent  not 
being  the  “king  bee”.  It  is  fortunate  that  the 
the  new  baby  is  arriving  before  this  child  is 
much  older,  as  the  problem,  although  big, 
will  not  be  as  hard  to  solve  this  fall  as  it 
would  be  two  years  from  now  if  the  same  pro- 
cedures were  continued.  This  child  happens 
to  be  an  excellent  eater  and  presents  no  prob- 
lem in  that  line.  If  he  should  continue  as  the 
only  child,  however,  he  would  be  a likely 
candidate  for  a group  that  I am  seeing  in  in- 
creasing numbers  each  year.  When  this 
group  enters  the  first  grade,  they  vomit  five 
mornings  a week,  but  never  on  Saturday  or 
Sunday.  They  cannot  adapt  themselves  to 
new  restrictions  at  school,  since  they  have 
had  free  reins  at  home. 

I would  not  be  surprised  if  you  should  say, 
“Why  should  you  advise  us  along  these  lines 
when  you  have  failed  with  the  mother  just 
under  discussion?”  I will  hasten  to  reply, 
“Nothing  is  one  hundred  per  cent  in  medi- 
cine”. However,  I am  sure  that  if  we  keep 
these  problems  and  these  situations  in  our 
minds  and  handle  them  correctly,  we  will 
succeed  in  many  instances.  You  must  re- 
member that  success  frequently  merges  into 
routine  experiences,  while  failures  stand  out 
like  a sore  thumb. 

Let  us  suppose  that  this  seventeen  months 
old  baby  had  been  a small  eater  by  nature, 
rather  than  ravenous  as  he  actually  is.  Can 
you  not  see  this  mother,  in  spite  of  many  ad- 
monitions, sitting  and  attempting  to  cram 
food  into  his  mouth?  This  increased  atten- 
tion would  be  wonderful  to  him  and  he  would 
probably  eat  less  and  less  in  order  to  get  in- 
creased attention.  Such  situations  may  be- 
come ludicrous.  Weech,  of  the  Children’s 
Hospital  in  Cincinnati,  vividly  describes  a 
father  sliding  down  the  bannister  before  each 
meal.  Otherwise,  the  child  would  not  eat.  He 
describes  another  child  who  would  never  eat 
an  egg  unless  his  father  squatted  down  in  the 


chair  and  laid  a fresh  one  solely  for  his  off- 
spring. 

How  do  such  situations  arise?  “Great  oaks 
from  little  acorns  grow”.  Therefore,  nip  the 
process  in  the  bud.  If  a young  baby  does  not 
eat  well,  so  what?  I have  never  seen  a baby 
nor  a child  starve  to  death.  Naturally  I am 
speaking  of  well  children.  Hunger  is  the  best 
appetizer.  On  one  occasion,  I was  in  a moth- 
er’s room  in  the  hospital  when  her  new  baby 
was  brought  in  for  feeding.  The  baby  was 
crying.  The  mother  actually  began  to  wring 
her  hands  and  shed  a few  tears,  stating,  “My 
poor  little  baby  is  hungry”.  I replied,  “Thank 
heavens!  Would  you  not  be  unhappy  if  he 
was  not  hungry?”  She  immediately  saw  the 
ridiculousness  of  the  situation  and  began  to 
laugh.  But  it  is  of  such  “acorns”  as  this  that 
real  problems  develop. 

When  a child  is  reported  to  be  a small — and 
you  notice  I prefer  to  use  the  word  small 
rather  than  poor — eater,  I advise  the  mother 
to  put  only  a small  helping  on  his  plate.  She 
should  put  even  less  on  the  plate  than  she 
thinks  he  is  going  to  eat.  If  she  should  serve 
him  a large  portion,  he  will  realize  the  im- 
possibility of  eating  all  of  it  and  will  probably 
decide  there  is  no  use  trying.  On  the  other 
hand,  if  a small  helping  is  offered,  he  will  eat 
it  and  will  have  the  satisfaction  of  having  ac- 
complished something — a job  well  done.  His 
ego  will  receive  a pick-up.  If  he  has  not  had 
sufficient,  he  will  ask  for  more,  and  what  a 
thrill  that  will  be  to  the  mother.  Satisfaction 
of  accomplishment  is  much  more  stimulating 
than  realization  of  failure.  Eating  should  be 
a privilege  and  not  an  obligation.  There 
should  be  neither  bribing  nor  punishment. 
Again  I state  that  I have  never  seen  a child 
starve  from  lack  of  food  when  it  was  avail- 
able. 

In  other  words,  I am  prone  to  feel  that 
many  of  our  modern  problems  in  infancy  and 
childhood  are  the  result  of  too  much  advice 
offered  parents  without  making  it  clear  that 
variations  may  occur  without  serious  ill  ef- 
fect. They  are  told  about  vitamins,  that  a 
quart  of  milk  daily  is  essential.  A radio  pro- 
gram advises  feeding  meats  at  two  to  three 


204 


J.  M.  A.  ALABAMA 


EMOTIONAL  PROBLEMS  IN  PEDIATRICS 


weeks  of  age.  Since  life  is  so  competitive  to- 
day, is  it  any  wonder  that  the  mother  is  much 
confused?  A little  knowledge  is  a dangerous 
thing.  Certainly  it  is  fine  if  a child  will  drink 
a quart  of  milk  daily.  However,  if  he  balks 
at  taking  more  than  sixteen  to  twenty  ounces 
a day,  he  should  be  let  alone.  Some  babies 
even  refuse  to  drink  any  milk.  Others  are  al- 
lergic to  it  and  it  has  to  be  omitted.  If  they 
are  given  adequate  supplemental  calcium, 
they  seem  to  do  just  as  well  as  the  child  tak- 
ing one  quart  of  milk  daily. 

I have  tried  to  solve  the  problem  of  ano- 
rexia by  stating  that  it  should  not  be  a prob- 
lem in  the  beginning  and,  therefore,  not  ac- 
centuated by  undue  forcing.  I am  reminded 
of  a case  where  parents  consulted  a psycholo- 
gist in  regard  to  their  child’s  small  appetite. 
When  his  advice  resulted  in  continued  failure, 
the  parents  urged  him  to  come  to  their  home 
for  a meal.  Arriving  some  time  before  din- 
ner, the  psychologist  tried  to  make  friends 
with  the  young  six-year-old  and  played  with 
him  and  observed  him  for  half  an  hour  or 
more.  Mealtime  arrived,  and  Johnny  sat  and 
looked  at  his  olate.  The  meal  hour  was  about 
over  and  Johnny  had  partaken  of  no  food. 
The  parents  were  gloating  and  seemed  to  say 
with  their  eyes  to  the  psychologist,  “I  told 
you  so”.  As  the  end  of  the  meal  approached, 
the  psychologist  leaned  over  and  whispered 
to  Johnny.  He  began  to  eat  ravenously,  and 
the  plate  was  soon  clean.  The  parents  were 
amazed  and  could  hardly  wait  to  find  out 
what  had  happened.  When  they  were  alone, 
they  rushed  up  and  inquired.  The  psycholo- 
gist replied,  “I  told  him,  ‘if  you  don’t  eat  that 
food  immediately.  I’m  going  to  beat  hell  out 
of  you’  ”.  Neither  medicine  nor  psychology 
is  one  hundred  per  cent  perfect. 

Children  are  smart,  even  from  the  earliest 
infancy.  I frequently  tell  parents  that  if  we 
could  understand  them  as  well  as  they  under- 
stand us,  we  would  make  better  parents.  Chil- 
dren have  a natural  sense  of  fairness.  They  do 
not  object  to  discipline,  even  severe  discipline, 
if  it  is  fair.  Whenever  you  tell  a child  to  do 
something,  or  say  “don’t”  to  him,  be  sure  to 
carry  out  your  request.  If  you  ever  give  in 


to  him  once,  you  are  literally  a lost  ball  in 
high  weeds.  It  is  well  recognized  that  a child 
cares  more  for  a parent  who  is  reasonable  in 
his  discipline  than  he  does  for  a parent  who 
is  wishy-washy.  One  parent  should  never 
change  the  request  of  another  parent.  If  one 
parent  should  think  that  the  request  is  un- 
reasonable, it  should  be  discussed  in  private 
and  not  in  front  of  the  child.  Parents  should 
not  disparage  each  other  in  the  presence  of 
the  child.  This  leads  to  a sense  of  insecurity. 

In  the  July  24,  1955  issue  of  “This  Week 
Magazine”,  Dr.  R.  F.  Hertz,  a British  writer 
and  teacher  with  a Ph.  D.  degree  in  psychol- 
ogy, presented  an  interesting  article  entitled 
“How  Parents  Should  Behave”.  He  conduct- 
ed an  international  mass  quiz  of  the  under-14 
year  children.  During  a three  year  period  al- 
most 100,000  children  in  the  United  States, 
Britain,  Canada,  Latin  America,  Australia, 
India  and  eleven  European  countries  took 
part  in  it.  Boys  and  girls  who  were  between 
the  ages  of  eight  and  fourteen  were  asked  to 
write  down  ten  rules  of  behavior  for  their  par- 
ents; that  is,  what  they  would  like  their  par- 
ents to  do  and  not  to  do.  They  came  up  with 
the  following  ten  rules  which  occurred  most 
often  in  the  children’s  answers.  The  remark- 
able thing  about  it  was  that  these  answers 
came  from  all  countries,  and  there  was  much 
unanimity  in  the  replies,  whether  they  were 
from  Los  Angeles  or  Rome,  Chicago  or  Lon- 
don. The  rules  were  as  follows: 

1.  Do  not  quarrel  in  front  of  your  children. 

2.  Treat  all  your  children  with  equal  affec- 
tion. 

3.  Never  lie  to  a child. 

4.  There  must  be  mutual  tolerance  be- 
between  parents. 

5.  There  should  be  comradeship  between 
parents  and  children. 

6.  Treat  your  children’s  friends  as  welcome 
visitors  in  your  home 

7.  Always  answer  children’s  questions. 

8.  Don’t  blame  or  punish  your  child  in  the 
presence  of  children  from  next  door. 

9.  Concentrate  on  your  child’s  good  points. 
Do  not  overemphasize  his  failings. 


205 


OCTOBER  I960— VOL.  30,  NO.  4 


EMOTIONAL  PROBLEMS  IN  PEDIATRICS 


10.  Be  constant  in  your  affection  and  in 
your  mood. 

Are  these  not  ten  wonderful  command- 
ments? 

In  summary,  I would  like  to  remind  you 
that  the  obstetrician  should  prepare  parents 
for  the  new  responsibility  that  will  soon  ar- 
rive. When  the  baby  bas  arrived,  the  parents 
should  be  given  some  very  pointed  instruc- 
tions and  advice.  The  parents  should  be  ad- 
vised as  to  what  they  might  expect,  and  they 
should  be  encouraged  to  consult  you  regard- 
ing any  problem,  rather  than  taking  too  much 
responsibility  upon  themselves.  Carnation 
Milk  advertises  milk  from  contented  cows. 
Certainly  parents  are  better  parents  if  they 
are  happy  and  contented  and  are  not  worry- 
ing about  their  baby.  If  the  baby  is  very 
small  and  is  growing  slowly,  remind  them 
that  precious  things  come  in  small  packages. 
Maybe  the  parents  can  brag  about  their  baby 
being  the  finest  small  baby  in  the  neighbor- 
hood. This  reminds  me  of  the  sudden  quan- 
dary of  a Texan.  He  was  bragging  lavishly 
of  his  native  state,  when  he  suddenly  stopped, 
speechless.  He  had  mentioned  dwarfs  but  he 
did  not  know  whether  to  brag  that  Texas  had 
the  largest  dwarf  or  the  smallest  dwarf. 

If  the  baby  is  slower  in  his  development 
than  the  next  door  neighbor’s  child  but  shows 
no  evidence  of  disease  nor  birth  trauma,  as- 
sure them  that  there  are  wide  variations  in 
development,  and  by  school  age  the  chances 
are  that  he  will  be  well  up  to  the  average. 
As  he  grows  older,  let  him  live  the  life  of  a 
child  and  not  as  a young  grownup.  Some  par- 
ents never  leave  home  and  return  without 
bringing  the  child  a gift.  You  have  read  of 
the  miseries  of  the  poor  little  rich  child.  To- 
day, parents  do  not  have  to  be  rich  to  indulge 
their  child.  It  is  not  infrequent  to  see  a child’s 
room  so  full  of  toys  that  one  can  hardly  enter 
it.  This  child  does  not  fully  enjoy  these  toys 
but  is  miserable  if  a new  one  does  not  arrive 
each  day.  Children  should  not  be  with  their 
parents  or  other  grownups  every  minute  of 
the  day.  I have  just  seen  a five  year  old  boy 
who  would  much  prefer  to  be  in  the  garden 
with  his  grandfather  than  to  be  with  other 


children.  This  situation  should  not  have  been 
allowed  to  develop.  Instead  of  making  mud- 
pies,  flying  kites  and  playing  hide-and-seek, 
too  many  children  today  sit  over  the  radio  or 
T.V.  I am  not  so  conservative  that  I think 
radio  and  T.V.  should  be  eliminated;  however, 
they  should  not  be  allowed  to  interfere  with 
sleep  and  meals.  It  should  be  unnecessary  to 
say  that  the  programs  should  be  selected,  but 
unfortunately  children  prefer  the  murders 
and  shoot-em-up  type,  and  these  are  per- 
mitted by  the  parents. 

At  an  early  age,  children  should  expect 
their  parents  to  leave  them  on  occasion,  so 
that  they  will  not  be  upset  by  it.  These  days, 
when  maids  are  a rarity,  an  increasing  num- 
ber of  children  are  terribly  upset  if  they  can- 
not constantly  put  their  finger  on  the  mother. 
These  parents  try  to  slip  away,  but  surely 
that  must  be  upsetting  when  the  child  even- 
tually discovers  what  has  happened. 

Another  important  thing  to  remember  is 
that  otherwise  most  intelligent  people  seem 
to  lose  their  sense  of  values  when  they  become 
parents.  They  seem  to  be  overwhelmed  by 
their  new  responsibilities  and  do  not  evaluate 
problems  concerning  the  infant  as  they  ordi- 
narily would.  One  night  a very  intelligent 
mother  phoned  me  that  her  child  had  the  ear- 
ache and  asked  what  to  do.  When  the  drops 
arrived,  she  again  phoned,  asking  which  ear 
to  put  the  drops  in.  When  I replied,  “The 
one  that  hurts’’,  she  said  “Thank  you”,  and 
was  quite  satisfied.  When  I told  another 
mother  to  give  her  baby  the  cod  liver  oil  at 
bath  time,  she  startled  me  a week  or  so  later 
when  she  told  me  that  she  was  putting  it  in 
the  bath  water. 

I cite  you  these  two  instances,  not  with  the 
idea  of  poking  fun  at  mothers,  but  to  impress 
upon  you  the  importance  of  being  simple  and 
clear  in  our  instructions.  We  should  take 
time  to  see  that  everything  is  properly  under- 
stood, and  greater  success  will  be  our  reward. 

Do  not  feel  that  I am  a pessimist.  A little 
girl  of  five  years  of  age  who  was  brought  to 
my  house  on  several  occasions  around  the  din- 
ner hour  so  that  her  parents  could  get  away 
to  the  movies  is  now  fully  grown  and  a normal 


206 


J.  M.  A.  ALABAMA 


EMOTIONAL  PROBLEMS  IN  PEDIATRICS 


individual.  As  we  look  around  at  the  adoles- 
cents and  the  young  grownups,  they  are  most- 
ly adequately  adjusted,  but  I believe  it  has 
been  occurring  in  spite  of  us  and  not  because 
of  our  training.  We  are  reading  more  and 
more  about  juvenile  delinquency  being  the 
result  of  improper  early  home  training.  For- 
tunately, the  number  of  juvenile  delinquents 
is  still  rather  small,  although  it  does  seem  to 
be  increasing.  In  another  recent  issue  of 
“This  Week  Magazine”  the  author  was  dis- 
cussing juvenile  delinquency.  He  listed  three 
D’s  as  the  chief  causes.  The  first  was  “Doting 
Parents”.  Some  parents  may  feel  afraid  to 
discipline  their  children.  However,  listen  to 
these  quotes:  At  a christening,  Robert  E.  Lee 
said,  “Teach  him  to  deny  himself”.  Bruce 
Catton,  Pulitzer  Prize  historian  said,  “Learn 
to  say  ‘no’  ”.  Catton  also  said,  “We  don’t  em- 
phasize self  denial  very  much  these  days. 


either  for  our  children  or  for  ourselves.  In- 
stead, we  concentrate  on  our  wants.  We  seem 
to  have  the  notion  that  the  world  owes  us 
all  mannner  of  things,  and  we  feel  abused 
when  w'e  don’t  get  them.  Self-discipline  is 
a bore;  and  as  a result,  we  are  perilously  close 
to  winning  an  unwelcome  fame  as  a land  of 
spoiled  children  and  discontented  adults”.  In 
the  Revised  Version  of  Proverbs  13:24,  we 
read,  “He  who  spares  the  rod  hates  his  son, 
but  he  who  loves  him  is  diligent  to  discipline 
him”. 

It  is  my  feeling  that  if  we  instruct  our  par- 
ents carefully  and  successfully — and  success- 
fully is  the  important  part — we  should  have 
children  that  develop  more  normally  and  will 
be  better  able  to  adjust  themselves  through- 
out childhood  and  adolescence,  which  should 
guide  them  into  normal,  mature  adults. 


OCTOBER  I960— VOL.  30,  NO.  4 


207 


Formes  Frusle  Ruptured  Ectopic  Pregnancy 


JACK  WOOL,  M.  D. 


Montgomery,  Alabama 


Usually  when  one  thinks  of  a patient  with 
a ruptured  tubal  pregnancy,  one  envisions  a 
female  in  the  first  trimester  of  pregnancy  who 
is  in  shock,  having  vaginal  bleeding  or  spot- 
ting and  complaining  of  acute  pain  in  the  low- 
er abdomen  of  sudden  onset.  This  descrip- 
tion, though  classic,  holds  true  in  only  a small 
percentage  of  those  patients  suffering  from 
a ruptured  extra  uterine  gestation. 

This  paper  will  review  a small  portion  of 
the  literature  and  add  71  more  cases  to  the 
growing  evidence  that  the  chronic  rupture  is 
the  more  prevalent.  It  is  also  hoped  that  an 
orderly  systematic  syndrome  can  be  here-in 
described  as  an  aid  to  making  the  diagnosis 
an  easier  one  and  the  condition  better  recog- 
nized. 

By  definition  it  is  felt  that  those  patients  in 
shock  belong  to  the  acute  group,  while  the 
chronic  group  is  composed  of  patients  with  a 
picture  not  unlike  that  of  chronic  salpingitis. 
Actually,  chronic  ruptured  tubal  pregnancy 
is  not  a good  name  for  this  syndrome.  The 
other  names  such  as  “obscure”,  “delayed”, 
“occult  tubal  rupture”',  “leaking  or  neglected 
ectopic  pregnancy”-’  also  seem  not  to  com- 
pletely convey  the  meaning  of  this  entity. 


Dr.  Wool  is  a graduate  of  the  College  of  Medicine 
of  the  University  of  Vermont,  a Fellow  of  the 
American  College  of  Surgeons,  a Diplomate  of  the 
American  Board  of  Surgeons,  and  a Fellow  of  the 
Southeastern  Surgical  Congress. 

Presented  at  the  9th  scientific  meeting  of  the 
Alabama  Chapter  of  the  American  College  of  Sur- 
geons, February  19,  1960,  Point  Clear,  Alabama. 


In  the  chronic  rupture,  pain  (an  almost  con- 
stant feature)  is  due  to  repeated  leaking  of 
blood  into  the  peritoneal  cavity,  and  which, 
if  severe  enough,  can  give  rise  to  anemia. 
Antibiotic  therapy  often  produces  a paradoxi- 
cal response  in  that  the  patient  seems  to  be  on 
the  road  to  recovery.  With  continued  blood 
loss,  however,  the  white  count  rises,  the 
hematocrit  falls,  the  temperature  again 
climbs,  and  one  often  is  misled  into  believing 
that  the  pelvic  mass  he  feels  represents  a 
chronic  salpingitis  or  tubo-ovarian  abscess. 

Pathologically  it  is  felt  that  the  background 
for  this  condition  is  the  scarred  tube  damaged 
by  repeated  attacks  of  infection,  but  kept 
patent  and  finally  healed  thru  the  use  of  anti- 
biotics. This,  too,  is  perhaps  the  reason  why 
the  chronic  phase  of  this  disease  is  becoming 
the  more  prevalent. 

That  the  age  of  the  patient  is  not  a factor 
in  this  disease  can  be  seen  in  the  fact  that  the 
group  in  this  series  ranged  from  17  to  41  years 
of  age  with  the  majority  in  the  mid  and  late 
twenties. 

On  a population  basis,  St.  Jude’s  Hospital, 
where  this  series  was  developed,  has  a pre- 
ponderantly higher  rate  of  Negro  admissions 
than  white.  The  breakdown  into  white  and 
colored  patients  is,  therefore,  not  representa- 
tive of  the  general  population.  For  the  record, 
however,  69  were  colored  and  2 white.  Of  this 
group  19  were  acute  and  52  chronic.  Hender- 
son and  Bean-  in  June  ’50  reported  on  302 
cases  in  which  there  were  91  acute  and  211 
chronic.  In  130  cases  of  Bell  and  Ingersol" 


208 


J.  M.  A.  ALABAMA 


RUPTURED  ECTOPIC  PREGNANCY 


there  were  85  per  cent  chronic  ruptures,  and 
15  per  cent  acute  as  patients  entering  in  shock. 


Reported  by: 

No.  of 
Cases 

Acute 

Chronic 

Henderson  & Bean 

302 

91 

211 

Bell  & Ingersol 

130 

20 

no 

St.  Jude’s  Hospital 

71 

19 

52 

The  present  study  revealed  that  previous 
pregnancies  had  occurred  in  all  but  six  pa- 
tients on  whom  this  information  was  avail- 
able. No  information  as  to  previous  preg- 
nancies was  obtainable  in  13  cases.  Two  pa- 
tients had  gone  thru  10  normal  pregnancies 
prior  to  their  rupture,  and  one  patient  in 
this  series  had  had  a previous  rupture. 

Rupture  generally  occurred  in  the  first 
trimester.  The  longest  period  of  gestation  at 
the  time  of  rupture  was  4 months.  An  at- 
tempt was  made  to  determine  how  soon  after 
rupturing  the  patient  presented  herself  for 
treatment.  It  was  found  that  fifteen,  and 
these  making  up  part  of  the  acute  group,  ap- 
peared on  the  first  day.  The  majority  ap- 
peared about  the  14th  day  post  rupture. 

Signs  and  Symptoms 

Symptomatically  the  majority  of  patients 
presented  the  classical  findings  of  amenor- 
rhea, pain,  vaginal  bleeding,  and  shock. 
Other  symptoms  were  more  of  a general  na- 
ture such  as  nausea,  vomiting,  and  diarrhea. 
In  a study  by  Johnson^  30  per  cent  of  the 
acute  patients  had  rectal  pressure  with  only 
5.5  per  cent  of  the  chronics  having  the  same 
complaints.  Dysuria  and  frequency  was 
found  in  15.3  per  cent  acute  and  16  per  cent 
chronic.  Breast  changes  were  seen  in  10.8 
per  cent  acute  and  15.6  per  cent  chronic. 

Amenorrhea  has  been  variously  reported  in 
from  39  per  cent  to  82  per  cent  of  cases.  The 
present  study  indicates  a need  for  a more 
careful  evaluation  of  this  complaint  when 
history  taking.  Too  often  it  is  assumed  that 
the  last  period  was  a normal  one.  More  care- 
ful and  detailed  questioning  brings  to  light 
the  fact  that  it  was  of  shorter  duration  and 
less  in  amount  than  usual. 

OCTOBER  I960— VOL.  30,  NO.  4 


Pain  was  present  in  all  but  one  of  our  71 
cases.  It  was  generally  described  as  low  and 
cramping  in  nature  and  would  occasionally 
radiate  into  the  rectum.  Sometimes  it  would 
be  characterized  as  dull  and  present  over  the 
entire  abdomen.  If  bleeding  was  brisk  and 
diaphragmatic  irritation  present,  shoulder 
pain  occurred.  This  finding  should  create  a 
high  index  of  suspicion. 

Vaginal  bleeding,  also  thought  of  as  a 
cardinal  sign  of  a ruptured  tubal  pregnancy, 
was  noted  to  be  recurrent,  occasionally  at- 
tended by  the  passage  of  a uterine  cast,  often 
merely  spotting,  and  sometimes  heavy  enough 
to  mislead  one  into  doing  a D & C.  This  was 
done  in  four  cases  in  the  series  herein  pre- 
sented. In  15  cases  no  bleeding  was  present. 
In  4 cases  no  notation  of  this  finding  could  be 
located  in  the  chart.  Nineteen  or  82  per  cent 
of  23  chronic  patients  in  our  series  bled  vagi- 
nally.  This  compares  well  with  86.8  per  cent' 
in  another  series. 

Shock  and  fainting  which  was  often  recur- 
rent signaled  the  acuteness  of  the  condition 
and  was  seen  in  nineteen  cases. 

Clinically  the  temperature  varied  from  sub 
normal  to  102  degrees  in  the  chronic  cases. 
The  pulse,  as  would  be  expected,  showed  a 
corresponding  rise.  Often  the  temperature 
seemed  to  respond  to  the  use  of  antibiotics 
only  to  later  act  as  though  this  was  an  in- 
fectious process  or  abscess  which  suddenly 
had  become  resistant  and  fever  would  recur. 
We  have  termed  this  a paradoxical  or  coinci- 
dental temperature  response. 

The  abdominal  findings  were  also  varied. 
A mass  could  be  palpated  in  44  per  cent  of 
Glen’s  patientsh  Forty-nine  or  69  per  cent  of 
our  patients  had  no  mass.  Tenderness,  spasm, 
distention,  and  rebound  were  frequently  not- 
ed in  both  acute  and  chronic  individuals.  Dis- 
tention was  said  to  be  more  severe  in  the 
acute  patient'. 

Pelvic  examination  revealed  a mass  in  53 
out  of  71  cases.  Of  this  group  of  53,  28  pa- 
tients were  in  the  chronic  group.  On  pelvic 
examination  one  often  noted  presumptive 
signs  of  pregnancy  such  as  a soft  blue  cervix. 

209 


RUPTURED  ECTOPIC  PREGNANCY 


Vaginal  bleeding  was  again  noted  in  52  or 
73  per  cent. 

Laboratory  Data 

The  laboratory  proved  to  be  an  aid  in  diag- 
nosis in  many  instances.  The  pregnancy  test, 
which  was  done  in  14  chronic  cases,  was  posi- 
tive in  six.  In  the  acute  series  only  two  tests 
had  been  done,  and  both  were  positive. 

The  blood  count  was  of  interest  since  it 
frequently  tended  to  confuse  the  picture 
through  being  misinterpreted.  Generally  the 
white  blood  count  was  elevated  between  10,- 
000  to  20,000  with  a corresponding  shift.  The 
elevation  was  of  course  secondary  to  perito- 
neal irritation  and  also  to  the  bleeding  itself. 
The  hemoglobin  and  hematocrit  were  usually 
low  at  the  onset  or  fell  as  the  patient  was  be- 
ing observed.  Frequently  with  antibiotic 
therapy  the  white  count  would  return  to 
normal.  This  was  another  paradox  since  the 
return  to  a normal  level  was  not  due,  as 
thought,  to  the  antibiotic,  but  rather  to  a de- 
crease in  the  amount  of  peritoneal  irritation 
when  bleeding  stopped.  When  bleeding  re- 
turned the  white  cells  again  became  elevated. 
There  was  a corresponding  decline  in  the 
hematocrit. 

Colpotomy,  or  cul  de  sac,  or  abdominal  as- 
piration at  this  time  generally  settled  the  di- 
agnosis. A positive  finding  was  obtained  in  20 
out  of  22  patients  on  whom  this  was  per- 
formed. The  blood  obtained  by  this  method 
should  not  clot  even  after  standing  for  ten 
minutes.  On  occasion,  pus  as  well  as  blood 
may  be  retrieved  through  the  same  needle 
puncture  especialy  if  an  abscess  is  concomi- 
tantly present.  In  one  case  aspiration  yielded 
nothing  but  pus.  When  a scalpel  was  intro- 
duced into  the  fluctuant  mass,  out  came  a 
stream  of  pus.  When  a Kelly  was  passed  in- 
to the  wound  for  better  drainage,  blood,  blood 
clots,  and  a fetus  gushed  forth.  Needless  to 
say  this  patient  was  quickly  laparotomized. 

On  further  review  of  the  records  we  find 
that  many  patients  with  ectopic  pregnancies 
were  confused  with  other  conditions  such  as 
chronic  salpingitis,  incomplete  abortion,  func- 
tional bleeding,  pelvic  abscess,  acute  appendi- 


citis, bleeding  fibroid,  ovarian  cyst,  tumor  and 
ruptured  ulcer.  By  far,  chronic  salpingitis 
was  the  diagnosis  with  which  the  condition 
was  most  frequently  confused. 

Treatment  of  the  extra  uterine  pregnancy 
consisted  of  first  attempting  to  replace  blood 
loss,  and  if  present,  treat  the  shock.  Surgery 
with  salpingectomy  as  soon  as  possible  was 
most  often  employed.  The  surgeon  in  some 
instances  also  did  a D & C,  hysterectomy,  in- 
cidental appendectomy,  excision  of  both 
tubes,  and  oophorectomy,  to  mention  a few. 

The  outcome  in  this  series  was  good.  None 
of  our  patients  died.  Two  patients  in  Parker 
& Ray’s’  series  died,  one  each  from  the  acute 
and  chronic  groups.  Henderson  & Bean’s' 
mortality  in  302  cases  ran  2.3  per  cent. 

Su  m mary 

In  summary  it  should  be  pointed  out  that 
the  diagnosis  of  chronic  ruptured  tubal  preg- 
nancy becomes  easy  if  one  is  looking  for  it. 
A patient  in  the  child  bearing  age  with  or 
without  the  history  of  a missed  period  with 
a picture  of  a chronic  salpingitis,  who  fails  to 
respond  to  antibiotics,  and  whose  hemaglobin 
and  hematocrit  continue  to  diminish  should 
be  viewed  with  a high  index  of  suspicion. 
When  this  train  of  symptoms  is  present,  col- 
potomy is  definitely  in  order  and  will  help  to 
confirm  the  diagnosis  of  ruptured  ectopic 
pregnancy  in  90  per  cent  of  the  cases.  Sal- 
pingitis was  the  diagnosis  with  which  the 
condition  was  most  easily  confused. 

REFERENCES 

1.  S.  L.  Parker,  Jr.,  M.D.,  and  Roy  T.  Parker: 

Chronic  Ectopic  Tubal.  Obstetrics  and  Gynecology, 
American  Journal  74:  1174-1180,  December,  1957 

2.  Henderson,  and  Bean:  Early  Uterine  Preg- 
nancies. Obstetrics  and  Gynecology,  American 
Journal  59:  1225-1235,  June,  1950 

3.  W.  O.  Johnson,  M.  D.:  Ruptured  Ectopic 

Pregnancies.  Obstetrics  and  Gynecology,  Ameri- 
can Journal  69:  1102,  November,  1952. 

4.  Harold,  Glen:  Diagnosis  of  Ectopic  Preg- 

nancy. Grace  Hospital  Bulletin,  Volume  135:  63- 
72,  January,  1957 

5.  Ware,  Reda,  Procter,  Lilly  and  Groves:  Ec- 
topic Pregnancy.  Virginia  Medical  Monthly,  85: 
238-250,  May,  1958 


210 


J.  M.  A.  ALABAMA 


Editorials 


PARTY  PLATFORMS  II 

In  last  month’s  Journal  we  reproduced  the 
first  of  the  platforms  of  the  two  major  parties. 
In  the  Association  Forum  of  this  issue  will  be 
found  the  platform  of  the  Republican  Party. 

The  Bulletin  of  the  Southern  States  Indus- 
trial Council  recently  carried  an  editorial  en- 
titled “Political  Philosophy  Counts.”  It  was 
written  by  Mr.  Thurman  Sensing.  In  his 
opening  statement,  Mr.  Sensing  said,  “The 
great  political  contest  now  in  progress  is  es- 
sentially a conflict  between  opposing  philoso- 
phies of  government.  Appeals  made  by  the 
candidates  have  a large  element  of  popular- 
ity-seeking and  also  contain  numerous  con- 
cessions to  the  practicalities  of  political  life. 
But  each  campaign  has  a hard  base  in  a con- 
cept of  what  American  government  ought  to 
be  in  the  twentieth  century.” 

As  was  said  last  month,  the  purpose  of  re- 
producing the  two  platforms  is  not  an  attempt 
to  tell  you  how  to  vote.  It  is,  however,  an  at- 
tempt to  put  as  much  information  before  you 
as  possible  so  that  you  may  make  your  own 
decision. 

Practically  everyone  supports  the  get-out- 
the-vote  campaigns  which  occur  prior  to  al- 
most every  election.  It  seems,  however,  that 
these  campaigns  do  not  go  far  enough.  Getting 
people  to  vote,  even  though  blindly,  will  sup- 
ply no  answers  to  the  problems  facing  our 
country  today.  We  must  have  an  informed 
electorate.  Issues  must  be  made  clear,  not 
clouded.  Facts  and  not  emotions  must  be  pre- 
sented so  that  a person  may  make  a logical 
decision. 

It  has  been  said  that  laws  are  made  by  Con- 
gress and  not  by  political  platforms  or  politi- 
cal parties.  This  statement  is  true;  but  like 
the  get-out-the-vote  campaigns,  it  does  not  go 


far  enough.  The  philosophy  by  which  a per- 
son is  known  is  all  important.  Despite  this 
day  and  age  of  creating  images  by  the  Madi- 
son Avenue  group,  certain  basic  truths  do 
and  will  stand. 

It  is  your  responsibility  to  he  a voter,  hut 
it  is  also  your  responsibility  to  be  an  informed 
voter.  Yon  vote  as  a free  man.  Do  not  vote 
blindly.  The  facts  are  before  you;  the  de- 
cision is  yours. 

Time  For  Action 

November  8 is  election  day.  It  is  the  day 
that  you,  as  a good  citizen,  should  exercise 
your  privilege  of  voting.  It  is  also  the  day 
that  you  should  be  certain  your  office  per- 
sonnel has  an  opportunity  to  exercise  the 
same  privilege. 

Between  pages  212  and  213  you  will  find  a 
card  for  use  in  your  office.  You  will  notice 
that  it  calls  for  a designated  time  during 
which  your  office  will  be  closed  so  that  you 
and  your  assistants  may  vote. 

This  card  will  serve  an  additional  purpose 
in  pointing  up  to  all  of  your  patients  the  in- 
tense interest  that  you  and  the  other  physi- 
cians share  in  being  an  active  part  of  our 
government. 

The  Association  feels  that  the  use  of  this 
card  can  be  of  great  value,  and  you  are  urged 
to  designate  a time  for  voting  and  to  let  your 
patients  know  this. 

Senator  Hill's  Comments  On 
Aid  To  Aged  Bill 

According  to  a recent  statement  by  Senator 
Lister  Hill,  the  medical  care  bill  for  the  aged 
— generally  known  as  the  Kerr  Bill — auth- 
orizes liberal  participation  by  the  federal 
government  in  paying  the  cost  of  medical  and 

21  I 


OCTOBER  I960— VOL.  30,  NO.  4 


EDITORIAL  SECTION 


hospital  care  tor  many  thousands  of  Alabam- 
ians 65  years  of  age  and  older,  whether  or  not 
these  senior  citizens  receive  old  age  assist- 
ance. 

The  bill  provides  an  additional  federal  con- 
tribution of  four  dollars  for  every  one  dollar 
contributed  by  Alabama  for  the  medical  care 
of  persons  receiving  old  age  assistance.  The 
result  is  to  make  available  to  the  Alabama 
program  during  the  first  year  approximately 
$4,155,000  in  additional  federal  participation 
with  no  increase  in  the  contribution  of  the 
state.  Senator  Hill  said. 

The  entire  increase  in  federal  participation 
would  be  used  as  “vendor  funds” — that  is,  di- 
rect payments  to  physicians  and  hospitals  for 
medical  services  to  any  of  the  99,000  elderly 
persons  now  on  the  state’s  old  age  assistance 
rolls,  he  said. 

For  the  purposes  of  the  bill,  the  term  “medi- 
cal services”  covers  all  doctor  bills,  hospitali- 
zation, dental  work,  nursing  home  care,  and 
many  other  such  services,  he  explained. 

In  addition  to  providing  increased  funds  for 
medical  care  of  the  99,000  persons  receiving 
old  age  assistance  in  Alabama,  he  continued, 
the  bill  authorizes  an  entirely  new  medical 
aid  program.  It  makes  available  for  payment 
by  the  federal  government  approximately  80 
per  cent  of  the  medical  care  to  those  among 
150,000  additional  persons  in  Alabama  who 
are  over  65  but  who  are  not  receiving  old  age 
assistance  and  may  need  financial  assistance 
in  paying  medical  bills,  he  said. 

The  bill  removes  the  age  50  qualification  for 
disability  benefits  under  the  present  Social 
Security  Law,  according  to  Senator  Hill. 

The  statement  concluded  by  pointing  out 
that  the  “sliding  scale”  provision  of  the  bill, 
under  which  Alabama  is  eligible  for  80  per 
cent  federal  participation  in  its  medical  care 
program,  is  based  on  the  Hill  formula  first 
written  into  federal  law  in  Senator  Hill’s 
Hospital  Construction  and  Survey  Act  of  1946 
(Hill-Burton).  The  formula  favors  the  rela- 
tively low  income  states,  requiring  greater 
local  participation  by  the  high  income  states. 

2 12 


Doctors  Warned  On  Menace  Of 
Misrepresented  Arthritis  Remedies 

The  nation’s  physicians  are  being  urged  to 
alert  their  patients  to  the  dangers  of  misrep- 
resented drugs  and  devices  currently  being 
promoted  tor  the  treatment  and  “cure”  of 
arthritis.  The  warning  appeared  in  a special 
article  written  for  the  Bulletin  On  POieumatic 
Diseases  by  Dr.  Ronald  W.  Lamont-Havers, 
medical  director  of  The  Arthritis  and  Rheu- 
matism Foundation. 

Within  recent  years  the  number  and  variety 
of  products  advertised  for  the  relief  of  arthri- 
tis, the  intent  and  ingenuity  of  their  claims, 
can  match  such  similar  exploitation  in  the 
past,  he  pointed  out.  He  cited  a recent 
Foundation  report,  “The  Misrepresentation  of 
Arthritis  Drugs  and  Devices  in  the  United 
States”,  which  documents  the  fact  that  over 
$250,000,000  a year  is  spent  on  products  and 
treatments  offered  with  misleadingly  implied 
benefits. 

Dr.  Lamont-Havers  told  Bulletin  readers 
that  many  of  these  products  are  “out-right 
quackery.”  Others,  he  explained,  contain  ac- 
tive ingredients,  usually  salicylates,  which  are 
promoted  with  the  implication  of  superior  re- 
lief over  cheaper,  equally  effective  medica- 
tions. 

The  Foundation’s  medical  director  struck 
out  at  so-called  “clinics”  for  arthritis,  uran- 
ium “cures”,  vibrators,  food  fads,  and  “health 
literature”  as  other  forms  of  quackery  cur- 
rently bilking  the  arthritis  sufferer. 

Dr.  Lamont-Havers  also  scored  what  he 
called  a “nonchalant,  laissez-faire”  attitude 
on  the  part  of  many  physicians  towai’d  this 
exploitation  of  arthritis  sufferers.  Deception 
of  the  credulous  for  profit  is  morally  repre- 
hensible whether  or  not  subsequent  damage 
to  the  patient  can  be  proven,  he  said. 

He  expressed  concern  over  the  effects  of 
disappointment  on  the  arthritic’s  attitude  to- 
ward legitimate  treatment.  Many  arthritis 
sufferers  place  great  faith  in  worthless  arthri- 
tis products;  and  then,  when  no  relief  comes, 
they  become  suspicious  of  all  proffered  help, 
even  authentic  medical  care.  Arthritis  regis- 
trations and  surveys  conducted  by  many 
Foundation  Chapters  show  that  nearly  50  per 


J.  M.  A.  ALABAMA 


EDITORIAL  SECTION 


cent  of  arthritis  victims  are  without  medical 
supervision  because  they  believe  that  little 
or  nothing  can  be  done  for  them. 

Dr.  Lamont-Havers  called  attention  to  a 
need  for  the  means  by  which  the  arthritis 
sufferer,  the  physician,  and  the  general  pub- 
lic can  obtain  advice  and  factual  information 
on  non-ethical  products  and  treatment  meth- 
ods. He  described  the  program  recently  in- 
augurated by  the  Foundation  to  help  meet 
this  need — a program  which  will  coordinate 
efforts  of  federal  agencies,  national  organiza- 
tions, and  other  groups  in  the  fight  against  the 
misleading  promotion  of  arthritis  products. 

Dr.  Lamont-Havers  emphasized  that  it  is 
not  ARF’s  objective  to  discourage  the  public 
from  purchasing  products  nor  to  attempt  to 
restrict  the  patient’s  right  to  self-medication. 
Rather,  he  said,  its  aim  is  to  attack  misrepre- 
sentation of  arthritis  products  and  to  present 
factual  information  to  protect  the  purchaser 
from  exploitation. 

Every  physician  owes  it  to  his  patients,  he 
concluded,  to  make  himself  aware  of  this 
multimillion  dollar  exploitation  and  to  co- 
operate actively  with  those  attempting  the 
often  difficult  task  of  protecting  them. 

Foreign  Physicians  Increasing  In  U.  S. 

The  number  of  foreign  physicians  training 
in  U.  S.  hospitals  has  almost  doubled  since 
1954,  according  to  a recent  report  published 
by  the  Institute  of  International  Education. 

This  year  our  hospitals  reported  9,457 
foreign  physicians  in  training,  an  increase  of 
13  per  cent  over  the  previous  year.  Part  of 
this  rise,  however,  resulted  from  a 9.3  per 
cent  increase  in  the  number  of  hospitals  re- 
porting to  the  survey. 

In  light  of  the  recent  action  of  the  Council 
on  Medical  Education  requiring  foreign  in- 
terns and  residents  to  pass  the  American 
Medical  Qualification  Examination,  this  an- 
nual increase  of  foreign  physicians  in  U.  S. 
hospitals  may  be  halted  and  even  reversed  in 
the  future. 

Physicians  from  the  Far  East  again  led  the 
foreign  medical  delegation  this  year  with  38.5 
per  cent  of  the  total  number,  followed  by  19.4 
per  cent  from  Latin  America,  18.1  per  cent 


from  Near  and  Middle  East,  and  16.3  per  cent 
from  Europe.  The  Philippines,  with  2,319 
was  again  the  largest  single  source  of  foreign 
men  and  women  studying  medicine  here  and 
accounted  alone  for  a 337  increase  over  last 
year’s  total  figure. 

These  statistics  are  revealed  in  the  sixth 
edition  of  Open  Doors,  the  Institute’s  annual 
statistical  report  on  education  exchange.  Be- 
sides foreign  physicians,  the  survey  also  re- 
ports on  the  exchange  of  U.  S.  and  foreign 
students  and  faculty  members. 

Forty-five  states,  the  District  of  Columbia, 
and  Puerto  Rico  reported  foreign  physicians 
in  their  hospitals,  with  New  York  claiming 
a full  25  per  cent  of  the  total.  Of  the  928 
hospitals  reporting  doctors  from  abroad,  15 
reported  more  than  50.  New  York’s  Bellevue 
Hospital  Center  led  the  list  with  87,  while  the 
King’s  County  Medical  Center  in  Brooklyn, 
New  York,  was  second  with  75. 

Open  Doors  reports  that  the  ratio  of  foreign 
residents  to  interns  remained  much  the  same 
as  in  previous  years,  with  the  1959-60  figures 
showing  6,912  residents  and  2,545  interns  from 
abroad  in  U.  S.  hospitals.  The  survey,  which 
this  year  is  able  to  report  on  the  fields  of 
specialization  of  the  foreign  resident  physi- 
cians, shows  that  1,401  were  training  in  gen- 
eral surgery,  787  in  general  medicine,  677  in 
pathology,  566  in  psychiatry,  and  540  in  ob- 
stetrics and  gynecology. 

New  Movie  Available 

A new  black  and  white  sound  film  featur- 
ing lectures,  panel  discussions  and  scientific 
exhibits  held  at  American  Medical  Associa- 
tion’s 109th  annual  meeting  in  Miami  Beach 
in  June  is  now  available  to  state  and  county 
medical  societies. 

The  film,  entitled  Medifilm  Report  II,  was 
produced  by  Schering  Corporation  in  cooper- 
ation with  AMA’s  department  of  medical  mo- 
tion pictures  and  television. 

Interested  groups  may  obtain  a copy  of 
Medifilm  Report  II  for  county  society  meet- 
ings by  writing  to  the  American  Medical 
Association,  535  North  Dearborn  Street,  Chi- 
cago, 111.,  or  to  the  audio-visual  department, 
Schering  Corporation,  Union,  New  Jersey. 


OCTOBER  I960— VOL.  30,  NO.  4 


213 


THE  FORWARD  LOOK 


Now  that  the  Mills-Kerr  Bill  has  been 
passed  by  the  Congress,  it  is  understood  that 
it  will  be  signed  by  President  Eisenhower. 

In  simple  terms,  the  bill  is  classed  as  a 
“voluntary  health  plan”  for  the  aged.  In 
reality  it  is  a hand  out  to  the  states  from  the 
general  tax  fund  of  the  federal  government 
to  be  matched  by  the  individual  states,  the 
state’s  share  from  the  government  to  be  from 
50  per  cent  to  80  per  cent,  depending  on  the 
per  capita  income  of  the  state  in  question. 
The  program  will  be  administered  by  each 
state  with  no  federal  strings  attached. 

With  the  passage  of  this  bill,  organized 
medicine  and  its  friends  have  won  a consid- 
erable victory  though  not  a complete  one. 
Instead  of  a foot  in  the  door,  let’s  say,  our 
opponents  have  a toe  in  it.  In  this  regard. 
Senators  Hill  and  Sparkman  must  be  highly 
commended  for  voting  against  the  socialized 
approach. 

A letter  received  from  Senator  Hill  an- 
nounces that  Alabama  will  receive  approxi- 
mately $4,000,000  each  year  from  the  federal 
government  for  the  care  of  the  needy  aged. 

What  is  the  next  step?  A state  agency 
must  be  set  up  to  administer  this  Health  Pro- 
gram. Shall  it  be  under  the  guidance  of  the 
State  Board  of  Health?  Or  shall  it  be  con- 
trolled by  the  Welfare  Department?  This  is 
the  first  administrative  move.  The  medical 
fraternity  must  assist,  suggest,  consider,  and 


do  their  share  in  arriving  at  the  most  satis- 
factory solution. 

Then  what  will  be  the  position  of  the  Ala- 
bama medical  profession  in  their  continued 
care  of  the  indigent,  the  aged,  and  the  needy 
aged.  Shall  it  be  as  in  the  past?  The  writer 
firmly  believes  that  it  should.  Otherwise  we 
are  not  consistent.  This  should  not  only  be 
done  in  Alabama  but  it  should  become  the 
national  program. 

The  good  will  incurred  should  be  of  incal- 
culable value  now,  and  even  more  so  in  the 
future. 

Be  advised  that  our  present  hard  won  vic- 
tory is  only  temporary.  The  serpent  will 
raise  his  head,  ready  to  strike,  at  every  politi- 
cal opportunity  in  the  days  to  come. 

Only  by  our  continuing  effort  and  by  more 
general  interest  among  the  members  of  our 
Association  can  we  (1)  do  “grass  roots”  edu- 
cation and  (2)  in  local  political  activity  con- 
tinue to  halt  the  leak  in  the  dyke. 


214 


J.  M.  A.  ALABAMA 


Building  A Better  America 
REPUBLICAN  PLATFORM  I960 


As  Adopted  By  The 
Republican  National  Convention 
July  27,  I960,  Chicago,  Illinois 


Preamble 

IThe  United  States  is  living  in  an  age  of 
profoundest  revolution.  The  lives  of  men  and 
of  nations  are  undergoing  such  transforma- 
tions as  history  has  rarely  recorded.  The 
birth  of  new  nations,  the  impact  of  new  ma- 
chines, the  threat  of  new  weapons,  the  stir- 
T ring  of  new  ideas,  the  ascent  into  a new  di- 
mension of  the  universe — everywhere  the 
* accent  falls  on  the  new. 

f At  such  a time  of  world  upheaval,  great 
I perils  match  great  opportunities — and  hopes, 
I ^ as  well  as  fears,  rise  in  all  areas  of  human  life. 
' j Such  a force  as  nuclear  power  symbolizes  the 
I greatness  of  the  choice  before  the  United 
States  and  mankind.  The  energy  of  the  atom 
^ could  bring  devastation  to  humanity.  Or  it 

■ OCTOBER  I960— VOL.  30,  NO.  4 


could  be  made  to  serve  men’s  hopes  for  peace 
and  progress — to  make  for  all  peoples  a more 
healthy  and  secure  and  prosperous  life  than 
man  has  ever  known. 

One  fact  darkens  the  reasonable  hopes  of 
free  men:  the  growing  vigor  and  thrust  of 

Communist  imperialism.  Everywhere  across 
the  earth,  this  force  challenges  us  to  prove 
our  strength  and  wisdom,  our  capacity  for 
sacrifice,  our  faith  in  ourselves  and  in  our  in- 
stitutions. 

Free  men  look  to  us  for  leadership  and  sup- 
port, which  we  dedicate  ourselves  to  give  out 
of  the  abundance  of  our  national  strength. 

The  fate  of  the  world  will  be  deeply  affect- 
ed, perhaps  determined,  by  the  quality  of 
American  leadership.  American  leadership 


215 


THE  ASSOCIATION  FORUM 


means  both  how  we  govern  ourselves  and  how 
we  help  to  influence  others.  We  deliberate 
the  choice  of  national  leadership  and  policy, 
mindful  that  in  some  measure  our  proposals 
involve  the  fate  of  mankind. 

The  leadership  of  the  United  States  must 
be  responsible  and  mature;  its  promises 
must  be  rational  and  practical,  soberly 
pledged  and  faithfully  undertaken.  Its  pur- 
poses and  its  aspirations  must  ascend  to  that 
high  ground  of  right  and  freedom  upon  which 
mankind  may  dwell  and  progress  in  decent 
security. 

We  are  impressed,  but  not  dismayed,  by  the 
revolutionary  turbulence  that  is  wracking  the 
world.  In  the  midst  of  violence  and  change, 
we  draw  strength  and  confidence  from  the 
changeless  principles  of  our  free  Constitution. 
Free  men  are  invincible  when  the  power  and 
courage,  the  patience  and  the  fortitude  latent 
in  them  ai’e  drawn  forth  by  reasonable  appeal. 

In  this  Republican  Platform  we  offer  to  the 
United  States  our  program — our  call  to  ser- 
vice, our  pledge  of  leadership,  our  proposal  of 
measures  in  the  public  interest.  We  call  up- 
on God,  in  whose  hand  is  every  blessing,  to 
favor  our  deliberations  with  wisdom,  our  na- 
tion with  endurance,  and  troubled  mankind 
everywhere  with  a righteous  peace. 


Foreign  Policy 

The  Republican  Party  asserts  that  the  sov- 
ereign purpose  of  our  foreign  policy  is  to  se- 
cure the  free  institutions  of  our  nation  against 
every  peril,  to  hearten  and  fortify  the  love 
of  freedom  everywhere  in  the  world,  and  to 
achieve  a just  peace  for  all  of  anxious  hu- 
manity. 

The  pre-eminence  of  this  Republic  requires 
of  us  a vigorous,  resolute  foreign  policy — in- 
flexible against  every  tyrannical  encroach- 
ment, and  mighty  in  its  advance  toward  our 
own  affirmative  goals. 

The  Government  of  the  United  States,  un- 
der the  administration  of  President  Eisen- 


hower and  Vice  President  Nixon,  has  demon- 
strated that  firmness  in  the  face  of  threatened 
aggression  is  the  most  dependable  safeguard 
of  peace.  We  now  reaffirm  our  determination 
to  defend  the  security  and  the  freedom  of  our 
country,  to  honor  our  commitments  to  our 
allies  at  whatever  cost  or  sacrifice,  and  never 
to  submit  to  force  or  threats.  Our  determina- 
tion to  stand  fast  has  forestalled  aggression 
before  Berlin,  in  the  Formosa  Straits,  and  in 
Lebanon.  Since  1954  no  free  nation  has  fallen 
victim  behind  the  Iron  Curtain.  We  mean  to 
adhere  to  the  policy  of  firmness  that  has 
served  us  so  well. 

We  are  unalterably  committed  to  maintain- 
ing the  security,  freedom  and  solidarity  of 
the  Western  Hemisphere.  We  support  Presi- 
dent Eisenhower’s  reaffirmation  of  the  Mon- 
roe Doctrine  in  all  its  vitality.  Faithful  to 
our  treaty  commitments,  we  shall  join  the 
Republics  of  the  Americas  against  any  inter- 
vention in  our  hemisphere,  and  in  refusing  to 
tolerate  the  establishment  in  this  hemisphere 
of  any  government  dominated  by  the  foreign 
rule  of  communism. 

In  the  Middle  East,  we  shall  continue  to 
support  the  integrity  and  independence  of  all 
the  states  of  that  area  including  Israel  and 
the  Arab  States. 

With  specific  reference  to  Israel  and  the 
Arab  Nations  we  urge  them  to  undertake  ne- 
gotiations for  a mutually  acceptable  settle- 
ment of  the  causes  of  tension  between  them. 
We  pledge  continued  efforts; 

• To  eliminate  the  obstacles  to  a lasting 
peace  in  the  area,  including  the  human  prob- 
lem of  the  Arab  refugees. 

• To  seek  an  end  to  transit  and  trade  re- 
strictions, blockades  and  boycotts. 

• To  secure  freedom  of  navigation  in  inter- 
national waterways,  the  cessation  of  dis- 
crimination against  Americans  on  the  basis 
of  religious  beliefs,  and  an  end  to  the  waste- 
ful and  dangerous  arms  race  and  to  the  threat 
of  an  arms  imbalance  in  the  area. 

Recognition  of  Communist  China  and  its 
admission  to  the  United  Nations  have  been 


216 


J.  M.  A.  ALABAMA 


THE  ASSOCIATION  FORUM 


fii’mly  opposed  by  the  Republican  Adminis- 
tration. We  will  continue  in  this  opposition 
because  of  compelling  evidence  that  to  do 
otherwise  would  weaken  the  cause  of  free- 
dom and  endanger  the  future  of  the  free 
peoples  of  Asia  and  the  world.  The  brutal 
suppression  of  the  human  rights  and  the  re- 
ligious traditions  of  the  Tibetan  people  is  an 
unhappy  evidence  of  the  need  to  persist  in 
our  policy. 

The  countries  of  the  free  world  have  been 
benefited,  reinforced  and  drawn  closer  to- 
gether by  the  vigor  of  American  support  of 
the  United  Nations,  and  by  our  participation 
in  such  regional  organizations  as  NATO, 
SEATO,  CENTO,  the  Organization  of  Ameri- 
can States  and  other  collective  security  alli- 
ances. We  assert  our  intention  steadfastly  to 
uphold  the  action  and  principles  of  these 
bodies. 

We  believe  military  assistance  to  our  allies 
under  the  mutual  security  program  should  be 
continued  with  all  the  vigor  and  funds  need- 
ed to  maintain  the  strength  of  our  alliances 
at  levels  essential  to  our  common  safety. 

The  firm  diplomacy  of  the  Eisenhower- 
Nixon  Administration  has  been  supported  by 
a military  power  superior  to  any  in  the  his- 
tory of  our  nation  or  in  the  world.  As  long 
as  world  tensions  menace  us  with  war,  we 
are  resolved  to  maintain  an  armed  power  ex- 
ceeded by  no  other. 

Under  Republican  administration,  the  Gov- 
ernment has  developed  original  and  construc- 
tive programs  in  many  fields — open  skies, 
atoms  for  peace,  cultural  and  technical  ex- 
changes, the  peaceful  uses  of  outer  space  and 
Antarctica — to  make  known  to  men  every- 
where our  desire  to  advance  the  cause  of 
peace.  We  mean,  as  a Party,  to  continue  in 
the  same  course. 

We  recognize  and  freely  acknowledge  the 
support  given  to  these  principles  and  policies 
by  all  Americans,  irrespective  of  party. 
Standing  as  they  do  above  partisan  challenge, 
such  principles  and  policies  will,  we  earnestly 
hope,  continue  to  have  bipartisan  support. 


We  established  a new  independent  agency, 
the  United  States  Information  Agency,  fully 
recognizing  the  tremendous  importance  of  the 
struggle  for  men’s  minds.  Today,  our  infor- 
mation program  throughout  the  world  is  a 
greatly  improved  medium  for  explaining  our 
policies  and  actions  to  audiences  overseas, 
answering  Communist  propaganda,  and  pro- 
jecting a true  image  of  American  life. 

This  is  the  Republican  record.  We  rededi- 
cate ourselves  to  the  principles  that  have 
animated  it;  and  we  pledge  ourselves  to  per- 
sist in  those  principles,  and  to  apply  them  to 
the  problems,  the  occasions,  and  the  oppor- 
tunities to  be  faced  by  the  new  Administra- 
tion. 

We  confront  today  the  global  offensive  of 
Communism,  increasingly  aggressive  and  vio- 
lent in  its  enterprises.  The  agency  of  that 
offensive  is  Soviet  policy,  aimed  at  the  sub- 
version of  the  world. 

Recently  we  have  noted  Soviet  Union  pre- 
texts to  intervene  in  the  affairs  of  newly  in- 
dependent countries,  accompanied  by  threats 
of  the  use  of  nuclear  weapons.  Such  inter- 
ventions constitute  a form  of  subversion 
against  the  sovereignty  of  these  new  nations 
and  a direct  challenge  to  the  United  Nations. 

The  immediate  strategy  of  the  Soviet  im- 
perialists is  to  destroy  the  world’s  confidence 
in  America’s  desire  for  peace,  to  threaten  with 
violence  our  mutual  security  arrangements, 
and  to  sever  the  bonds  of  amity  and  respect 
among  the  free  nations.  To  nullify  the  Soviet 
conspiracy  is  our  greatest  task.  The  United 
States  faces  this  challenge  and  resolves  to 
meet  it  with  courage  and  confidence. 

To  this  end  we  will  continue  to  support  and 
strengthen  the  United  Nations  as  an  instru- 
ment for  peace,  for  international  cooperation, 
and  for  the  advancement  of  the  fundamental 
freedoms  and  humane  interests  of  mankind. 

Under  the  United  Nations  we  will  work  for 
the  peaceful  settlement  of  international  dis- 
putes and  the  extension  of  the  rule  of  law  in 
the  world. 


OCTOBER  I960— VOL.  30,  NO.  4 


217 


THE  ASSOCIATION  FORUM 


And,  in  furtherance  of  President  Eisen- 
hower’s proposals  for  the  peaceful  use  of 
space,  we  suggest  that  the  United  Nations 
take  the  initiative  to  develop  a body  of  law 
applicable  thereto. 

Through  all  the  calculated  shifts  of  Soviet 
tactics  and  mood,  the  Eisenhower-Nixon  Ad- 
ministration has  demonstrated  its  willingness 
to  negotiate  in  earnest  with  the  Soviet  Union 
to  arrive  at  just  settlements  for  the  reduction 
of  world  tensions.  We  pledge  the  new  Ad- 
ministration to  continue  in  the  same  course. 

We  are  similarly  ready  to  negotiate  and  to 
institute  realistic  methods  and  safeguards  for 
disarmament,  and  for  the  suspension  of  nu- 
clear tests.  We  advocate  an  early  agreement 
by  all  nations  to  forego  nuclear  tests  in  the 
atmosphere,  and  the  suspension  of  other  tests 
as  verification  techniques  permit.  We  sup- 
port the  President  in  any  decision  he  may 
make  to  reevaluate  the  question  of  resump- 
tion of  underground  nuclear  explosions  test- 
ing, if  the  Geneva  Conference  fails  to  pro- 
duce a satisfactory  agreement.  We  have  deep 
concern  about  the  mounting  nuclear  arms 
race.  This  concern  leads  us  to  seek  disarma- 
ment and  nuclear  agreements.  And  an  equal 
concern  to  protect  all  peoples  from  nuclear 
danger,  leads  us  to  insist  that  such  agree- 
ments have  adequate  safeguards. 

We  recognize  that  firm  political  and  mili- 
tary policies,  while  imperative  for  our  se- 
curity, cannot  in  themselves  build  peace  in 
the  world. 

In  Latin  America,  Asia,  Africa  and  the  Mid- 
dle East,  peoples  of  ancient  and  recent  in- 
dependence, have  shown  their  determination 
to  improve  their  standards  of  living,  and  to 
enjoy  an  equality  with  the  rest  of  mankind 
in  the  enjoyment  of  the  fruits  of  civilization. 
This  determination  has  become  a primary 
fact  of  their  political  life.  We  declare  our- 
selves to  be  in  sympathy  with  their  aspira- 
tions. 

We  have  already  created  unprecedented  di- 
mensions of  diplomacy  for  these  purposes. 
We  recognize  that  upon  our  support  of  well- 


conceived  programs  of  economic  cooperation 
among  nations  rest  the  best  hopes  of  hundreds 
of  millions  of  friendly  people  for  a decent 
future  for  themselves  and  their  children.  Our 
mutual  security  program  of  economic  help 
and  technical  assistance;  the  Development 
Loan  Fund,  the  Inter-American  Bank,  the 
International  Development  Association  and 
the  Food  for  Peace  Program,  which  create  the 
conditions  for  progress  in  less-developed 
countries;  our  leadership  in  international  ef- 
forts to  help  children,  eliminate  pestilence 
and  disease  and  aid  refugees — these  are  pro- 
grams wise  in  concept  and  generous  in  pur- 
pose. We  mean  to  continue  in  support  of 
them. 

Now  we  propose  to  further  evolution  of  our 
programs  for  assistance  to  and  cooperation 
with  other  nations,  suitable  to  the  emerging 
needs  of  the  future. 

We  will  encourage  the  countries  of  Latin 
America,  Africa,  the  Middle  East  and  Asia,  to 
initiate  appropriate  regional  groupings  to 
work  out  plans  for  economic  and  educational 
development.  We  anticipate  that  the  United 
Nations  Special  Fund  would  be  of  assistance 
in  developing  such  plans.  The  United  States 
would  offer  its  cooperation  in  planning,  and 
the  provision  of  technical  personnel  for  this 
purpose.  Agreeable  to  the  developing  na- 
tions, we  would  join  with  them  in  inviting 
countries  with  advanced  economies  to  share 
with  us  a proportionate  part  of  the  capital 
and  technical  aid  required.  We  would  em- 
phasize the  increasing  use  of  private  capital 
and  government  loans,  rather  than  outright 
grants,  as  a means  of  fostering  independence 
and  mutual  respect.  The  President’s  recent 
initiative  of  a joint  partnership  program  for 
Latin  America  opens  the  way  to  this  ap- 
proach. 

We  would  propose  that  such  groupings 
adopt  means  to  attain  viable  economies  fol- 
lowing such  examples  as  the  European  Com- 
mon Market.  And  if  from  these  institutions, 
there  should  follow  stronger  economic  and 
political  unions,  we  would  welcome  them 
with  our  support. 


218 


J.  M.  A.  ALABAMA 


THE  ASSOCIATION  FORUM 


Despite  the  counterdrive  of  international 
Communism,  relentless  against  individual 
freedom  and  subversive  of  the  sovereignty 
of  nations,  a powerful  drive  for  freedom  has 
swept  the  world  since  World  War  II  and  many 
heroic  episodes  in  the  Communist  countries 
have  demonstrated  anew  that  freedom  will 
not  die. 

The  Republican  Party  reaffirms  its  de- 
termination to  use  every  peaceful  means  to 
help  the  captive  nations  toward  their  inde- 
pendence, and  thus  their  freedom  to  live  and 
worship  according  to  conscience.  We  do  not 
condone  the  subjugation  of  the  peoples  of 
Hungary,  Poland,  East  Germany,  Czechoslo- 
vakia, Rumania,  Albania,  Bulgaria,  Latvia, 
Lithuania,  Estonia,  and  other  once-free  na- 
tions. We  are  not  shaken  in  our  hope  and  be- 
lief that  once  again  they  will  rule  themselves. 

Our  time  surges  with  change  and  challenge, 
peril  and  great  opportunities.  It  calls  us  to 
great  tasks  and  efforts — for  free  men  can 
hope  to  guard  freedom  only  if  they  prove 
capable  of  historic  acts  of  wisdom  and  cour- 
age. 

Dwight  David  Eisenhower  stands  today 
throughout  the  world  as  the  greatest  cham- 
pion of  peace  and  justice  and  good. 

The  Republican  Party  brings  to  the  days 
ahead  trained,  experienced,  mature  and  cour- 
ageous leadership. 

Our  Party  was  born  for  freedom’s  sake.  It 
is  still  the  Party  of  full  freedom  in  our  coun- 
try. As  in  Lincoln’s  time,  our  Party  and  its 
leaders  will  meet  the  challenges  and  oppor- 
tunities of  our  time  and  keep  our  country  the 
best  and  enduring  hope  of  freedom  for  the 
world. 


National  Defense 

The  future  of  freedom  depends  heavily  up- 
on America’s  military  might  and  that  of  her 
allies.  Under  the  Eisenhower-Nixon  Admin- 
istration, our  military  might  has  been  forged 
into  a power  second  to  none.  This  strength, 
tailored  to  serve  the  needs  of  national  policy. 


has  deterred  and  must  continue  to  deter  ag- 
gression and  encourage  the  growth  of  free- 
dom in  the  world.  This  is  the  only  sure  way 
to  a world  at  peace. 

We  have  checked  aggression.  We  ended 
the  war  in  Korea.  We  have  joined  with  free 
nations  in  creating  strong  defenses.  Swift 
technological  change  and  the  warning  signs 
of  Soviet  aggressiveness  make  clear  that  in- 
tensified and  courageous  efforts  are  neces- 
sary, for  the  new  problems  of  the  1960’s  will 
of  course  demand  new  efforts  on  the  part  of 
our  entire  nation.  The  Republican  Party  is 
pledged  to  making  certain  that  our  arms,  and 
our  will  to  use  them,  remain  superior  to  all 
threats.  We  have,  and  will  continue  to  have, 
the  defenses  we  need  to  protect  our  freedom. 

The  strategic  imperatives  of  our  national  de- 
fense policy  are  these: 

• A second-strike  capability,  that  is,  a nu- 
clear retaliatory  power  than  can  survive  sur- 
prise attack,  strike  back,  and  destroy  any 
possible  enemy. 

• Highly  mobile  and  versatile  forces,  includ- 
ing forces  deployed,  to  deter  or  check  local 
aggressions  and  “brush  fire  wars”  which 
might  bring  on  all-out  nuclear  war. 

• National  determination  to  employ  all  nec- 
essary military  capabilities  so  as  to  render 
any  level  of  aggression  unprofitable.  De- 
terrence of  war  since  Korea,  specifically,  has 
been  the  result  of  our  firm  statement  that  we 
will  never  again  permit  a potential  aggres- 
sor to  set  the  ground  rules  for  his  aggression; 
that  we  will  respond  to  aggression  with  the 
full  means  and  weapons  best  suited  to  the 
situation. 

Maintenance  of  these  imperatives  requires 
these  actions: 

• Unremitting  modernization  of  our  retalia- 
tory forces,  continued  development  of  the 
manned  bomber  well  into  the  missile  age, 
with  necessary  numbers  of  these  bombers 
protected  through  dispersal  and  airborne 
alert. 

• Development  and  production  of  new  stra- 
tegic weapons,  such  as  the  Polaris  submarine 
and  ballistic  missile.  Never  again  will  they 

2 19 


OCTOBER  I960— VOL.  30,  NO.  4 


THE  ASSOCIATION  FORUM 


be  neglected,  as  intercontinental  missile  de- 
velopment was  neglected  between  the  end  of 
World  War  II  and  1953. 

• Accelerate  as  necessary,  development  of 
hardening,  mobility,  dispersal  and  produc- 
tion programs  for  long-range  missiles  and  the 
speedy  perfection  of  new  and  advanced  gen- 
erations of  missiles  and  anti-missile  missiles. 

• Intensified  development  of  active  civil  de- 
fense to  enable  our  people  to  protect  them- 
selves against  the  deadly  hazards  of  atomic 
attack,  particularly  fallout;  and  to  develop  a 
new  program  to  build  a reserve  of  storable 
food,  adequate  to  the  needs  of  the  population 
after  an  atomic  attack. 

• Constant  intelligence  operations  regarding 
Communist  military  preparations  to  prevent 
another  Pearl  Harbor. 

• A military  establishment  organized  in  ac- 
cord with  a national  strategy  which  enables 
the  unified  commands  in  Europe,  the  Pacific, 
and  this  continent  to  continue  to  respond 
promptly  to  any  kind  of  aggression. 

• Strengthening  of  the  military  might  of  the 
free-world  nations  in  such  ways  as  to  encour- 
age them  to  assume  increasing  responsibility 
for  regional  security. 

• Continuation  of  the  “long  pull”  prepared- 
ness policies  which,  as  inaugurated  under  the 
Eisenhower-Nixon  Administration,  have 
avoided  the  perilous  peaks  and  slumps  of  de- 
fense spending  and  planning  which  marked 
earlier  administrations. 

There  is  no  price  ceiling  on  America’s  se- 
curity. The  United  States  can  and  must  pro- 
vide whatever  is  necessary  to  insure  its  own 
security  and  that  of  the  free  world  and  to  pro- 
vide any  necessary  increased  expenditures 
to  meet  new  situations,  to  guarantee  the  op- 
portunity to  fulfill  the  hopes  of  men  of  good 
will  eveywhere.  To  provide  more  would  be 
wasteful.  To  provide  less  would  be  catas- 
trophic. Our  defense  posture  must  remain 
steadfast,  confident,  and  superior  to  all  po- 
tential foes. 


Economic  Growth  and  Business 

To  provide  the  means  to  a better  life  for  in- 
dividual Americans  and  to  strengthen  the 
forces  of  freedom  in  the  world,  we  count  on 
the  proved  productivity  of  our  free  economy. 

Despite  the  lamentations  of  the  opposition 
in  viewing  the  economic  scene  today,  the 
plain  fact  is  that  our  500  billion  dollar  econ- 
omy finds  more  Americans  at  work,  earning 
more,  spending  more,  saving  more,  investing 
more,  building  more  than  ever  before  in  his- 
tory. The  well-being  of  our  people,  by  vir- 
tually every  yardstick,  has  greatly  advanced 
under  this  Republican  Administration. 

But  we  can  and  must  do  better.  We  must 
raise  employment  to  even  higher  levels  and 
utilize  even  more  fully  our  expanding  over- 
all capacity  to  produce.  We  must  quicken 
the  pace  of  our  economic  growth  to  prove 
the  power  of  American  free  enterprise  to 
meet  growing  and  urgent  demands:  to  sus- 
tain our  military  posture,  to  provide  jobs  for 
a growing  labor  force  in  a time  of  rapid  tech- 
nological change,  to  improve  living  standards, 
to  serve  all  the  needs  of  an  expanding  popu- 
lation. 

We  therefore  accord  high  priority  to  vigor- 
ous economic  growth  and  recognize  that  its 
mainspring  lies  in  the  private  sector  of  the 
economy.  We  must  continue  to  foster  a 
healthy  climate  in  that  sector.  We  reject  the 
concept  of  artificial  growth  forced  by  massive 
new  federal  spending  and  loose  money  poli- 
cies. The  only  effective  way  to  accelerate 
economic  growth  is  to  increase  the  traditional 
strengths  of  our  free  economy — initiative  and 
investment,  productivity  and  efficiency.  To 
that  end  we  favor: 

• Broadly-based  tax  reform  to  foster  job- 
making and  growth-making  investment  for 
modernization  and  expansion,  including  rea- 
listic incentive  depreciation  schedules. 

• Use  of  the  full  powers  of  government  to 
prevent  the  scourges  of  depression  and  infla- 
tion. 

• Elimination  of  featherbedding  practices  by 
labor  and  business. 


220 


J.  M.  A.  ALABAMA 


THE  ASSOCIATION  FORUM 


• Maintenance  of  a stable  dollar  as  an  indis- 
pensable means  to  progress. 

• Relating  wage  and  other  payments  in  pro- 
duction to  productivity — except  when  neces- 
sary to  correct  inequities- — in  order  to  help  us 
stay  competitive  at  home  and  abroad. 

• Spurring  the  economy  by  advancing  the 
successful  Eisenhower-Nixon  program  foster- 
ing new  and  small  business,  by  continued  ac- 
tive enforcement  of  the  anti-trust  laws,  by 
protecting  consumers  and  investors  against 
the  hazard  and  economic  waste  of  fraudulent 
and  criminal  practices  in  the  market  place, 
and  by  keeping  the  federal  government  from 
unjustly  competing  with  private  enterprise 
upon  which  Americans  mainly  depend  for 
their  livelihood. 

• Continued  improvement  of  our  vital  trans- 
portation network,  carrying  forward  rapidly 
the  vast  Eisenhower-Nixon  national  highway 
program  and  promoting  safe,  efficient,  com- 
petitive and  integrated  transport  by  air,  road, 
rail  and  water  under  equitable,  impartial  and 
minimal  regulation  directed  to  those  ends. 

• Carrying  forward,  under  the  Trade  Agree- 
ments Act,  the  policy  of  gradual  selective— 
and  truly  reciprocal — reduction  of  unjustifi- 
able barriers  to  trade  among  free  nations. 
We  advocate  effective  administration  of  the 
Act’s  escape  clause  and  peril  point  provisions 
to  safeguard  American  jobs  and  domestic  in- 
dustries against  serious  injury.  In  support  of 
our  national  trade  policy  we  should  continue 
the  Eisenhower-Nixon  program  of  using  this 
government’s  negotiating  powers  to  open 
markets  abroad  and  to  eliminate  remaining 
discrimination  against  our  goods.  We  should 
also  encourage  the  development  of  fair  labor 
standards  in  exporting  countries  in  the  inter- 
est of  fair  competition  in  international  trade. 
We  should,  too,  expand  the  Administration’s 
export  drive,  encourage  tourists  to  come  from 
abroad,  and  protect  U.  S.  investors  against 
arbitrary  confiscations  and  expropriations  by 
foreign  governments.  Through  these  and 
other  constructive  policies,  we  will  better  our 
international  balance  of  payments. 

OCTOBER  I960— VOL.  30,  NO.  4 


• Discharge  by  government  of  responsibility 
for  those  activities  which  the  private  sector 
cannot  do  or  cannot  so  well  do,  such  as  con- 
structive federal-local  action  to  aid  areas  of 
chronic  high  unemployment,  a sensible  farm 
policy,  development  and  wise  use  of  natural 
resources,  suitable  support  of  education  and 
research,  and  equality  of  job  opportunity  for 
all  Americans. 

Action  on  these  fronts,  designed  to  release 
the  strongest  productive  force  in  human  af- 
fairs—the  spirit  of  individual  enterprise — 
can  contribute  greatly  to  our  goal  of  a steady, 
strongly  growing  economy. 


Labor 

America’s  growth  cannot  be  compartmen- 
talized. Labor  and  management  cannot  pros- 
per without  each  other.  They  cannot  ignore 
their  mutual  public  obligation. 

Industrial  harmony,  expressing  these  mu- 
tual interests,  can  best  be  achieved  in  a cli- 
mate of  free  collective  bargaining,  with  mini- 
mal government  intervention  except  by  medi- 
ation and  conciliation. 

Even  in  dealing  with  emergency  situations 
imperiling  the  national  safety,  ways  of  so- 
lution must  be  found  to  enhance  and  not  im- 
pede the  processes  of  free  collective  bargain- 
ing— carefully  considered  ways  that  are  in 
keeping  with  the  policies  of  national  labor 
relations  legislation  and  with  the  need  to 
strengthen  the  hand  of  the  President  in  deal- 
ing with  such  emergencies. 

In  the  same  spirit.  Republican  leadership 
will  continue  to  encourage  discussions,  away 
from  the  bargaining  table,  between  labor  and 
management  to  consider  the  mutual  interest 
of  all  Americans  in  maintaining  industrial 
peace. 

Republican  policy  firmly  supports  the  right 
of  employers  and  unions  freely  to  enter  into 
agreements  providing  for  the  union  shop  and 
other  forms  of  union  security  as  authorized  by 
the  Labor-Management  Relations  Act  of  1947 
(the  Taft-Hartley  Act). 

22  I 


THE  ASSOCIATION  FORUM 


Republican-sponsored  legislation  has  sup- 
ported the  right  of  union  members  to  full  par- 
ticipation in  the  affairs  of  their  union  and 
their  right  to  freedom  from  racketeering  and 
gangster  interference  whether  by  labor  or 
management  in  labor-management  relations. 

Republican  action  has  given  to  millions  of 
American  working  men  and  women  new  or 
expanded  protection  and  benefits,  such  as: 

Increased  federal  minimum  wage; 

Extended  coverage  of  unemployment  insur- 
ance and  the  payment  of  additional  temporary 
benefits  provided  in  1958-59; 

Improvement  of  veterans’  re-employment 
rights; 

Extension  of  federal  workman’s  compensa- 
tion coverage  and  increase  of  benefits; 

Legislative  assurance  of  safety  standards 
for  longshore  and  harbor  workers  and  for  the 
transportation  of  migratory  workers; 

An  increase  of  railroad  workers’  retirement 
and  disability  benefits. 

Seven  past  years  of  accomplishments,  how- 
ever, are  but  a base  to  build  upon  in  fostering, 
promoting  and  improving  the  welfare  of 
America’s  working  men  and  women,  both  or- 
ganized and  unorganized.  We  pledge,  there- 
fore, action  on  these  constructive  lines; 

• Diligent  administration  of  the  amended 
Labor-Management  Relations  Act  of  1947 
(Taft-Hartley  Act)  and  the  Labor-Manage- 
ment Reporting  and  Disclosure  Act  of  1959 
(Landrum-Griffin  Act)  with  recommenda- 
tions for  improvements  which  experience 
shows  are  needed  to  make  them  more  ef- 
fective or  remove  any  inequities. 

• Correction  of  defects  in  the  Welfare  and 
Pension  Plans  Disclosure  Act  to  protect  em- 
ployees’ and  beneficiaries’  interests. 

• Upward  revision  in  amount  and  extended 
coverage  of  the  minimum  wage  to  several 
million  more  workers. 

• Strengthening  the  unemployment  insur- 
ance system  and  extension  of  its  benefits. 

• Improvement  of  the  eight-hour  laws  relat- 
ing to  hours  and  overtime  compensation  on 


federal  and  federally-assisted  construction, 
and  continued  vigorous  enforcement  and  im- 
provement of  minimum  wage  laws  for  federal 
supply  and  construction  contracts. 

• Continued  improvement  of  manpower 
skills  and  training  to  meet  a new  era  of  chal- 
lenges, including  action  programs  to  aid  older 
workers,  women,  youth,  and  the  physically 
handicapped. 

• Encouragement  of  training  programs  by 
labor,  industry  and  government  to  aid  in  find- 
ing new  jobs  for  persons  dislocated  by  auto- 
mation or  other  economic  changes. 

® Improvement  of  job  opportunities  and 
working  conditions  of  migratory  farm  work- 
ers. 

® Assurance  of  equal  pay  for  equal  work  re- 
gardless of  sex;  encouragement  of  programs 
to  insure  on-the-job  safety,  and  encourage- 
ment of  the  States  to  improve  their  labor 
standards  legislation,  and  to  improve  veter- 
ans’ employment  rights  and  benefits. 

• Encouragement  abroad  of  free  democratic 
institutions,  higher  living  standards  and  high- 
er wages  through  such  agencies  as  the  Inter- 
national Labor  Organization,  and  cooperation 
with  the  free  trade  union  movement  in 
strengthening  free  labor  throughout  the 
world. 


Agriculture 

Americans  are  the  best-fed  and  the  best- 
clothed  people  in  the  world.  Our  challenge 
fortunately  is  one  of  dealing  with  abundance, 
not  overcoming  shortage.  The  fullness  of  our 
fields,  forests  and  grazing  lands  is  an  im- 
portant advantage  in  our  struggle  against 
worldwide  tyranny  and  our  crusade  against 
poverty.  Our  farmers  have  provided  us  with 
a powerful  weapon  in  the  ideological  and  eco- 
nomic struggle  in  which  we  are  now  engaged. 

Yet,  far  too  many  of  our  farm  families,  the 
source  of  this  strength,  have  not  received  a 
fair  return  for  their  labors.  For  too  long, 
Democratic-controlled  Congresses  have  stale- 


222 


J.  M.  A.  ALABAMA 


THE  ASSOCIATION  FORUM 


mated  progress  by  clinging  to  obsolete  pro- 
grams conceived  for  different  times  and  dif- 
ferent problems. 

Promises  of  specific  levels  of  price  support 
or  a single  type  of  program  for  all  agriculture 
are  cruel  deceptions  based  upon  the  pessimis- 
tic pretense  that  only  with  rigid  controls  can 
farm  families  be  aided.  The  Republican  Par- 
ty will  provide  within  the  framework  of  in- 
dividual freedom  a greater  bargaining  power 
to  assure  an  equitable  return  for  the  work 
and  capital  supplied  by  farmers. 

The  Republican  Party  pledges  itself  to  de- 
velop new  programs  to  improve  and  stabilize 
farm  family  income.  It  recognizes  two  main 
challenges:  the  immediate  one  of  utilizing 

income-depressing  surpluses,  and  the  long- 
range  one  of  steady  balanced  growth  and  de- 
velopment with  a minimum  of  federal  inter- 
ference and  control. 

To  utilize  imviediately  surpluses  in  an  orderly 
manner,  with  a minimum  impact  on  domestic 
and  foreign  markets,  we  pledge: 

® Intensification  of  the  Food  for  Peace  pro- 
gram, including  new  cooperative  efforts 
among  food-surplus  nations  to  assist  the  hun- 
gry peoples  in  less  favored  areas  of  the  world. 

• Payment-in-kind,  out  of  existing  surpluses, 
as  part  of  our  land  retirement  program. 

• Creation  of  a Strategic  Food  Reserve  prop- 
erly dispersed  in  forms  which  can  be  pre- 
served for  long  periods  against  the  contin- 
gency of  grave  national  emergency. 

• Strengthened  efforts  to  distribute  sur- 
pluses to  schools  and  low-income  and  needy 
citizens  of  our  own  country. 

• A reorganization  of  Commodity  Credit 
Corporation’s  inventory  management  opera- 
tions to  reduce  competition  with  the  market- 
ings of  farmers. 

To  assure  steady  balanced  growth  and  agri- 
cultural progress,  we  pledge: 

• A crash  research  program  to  develop  in- 
dustrial and  other  uses  of  farm  products. 

» Use  of  price  supports  at  levels  best  fitted 
to  specific  commodities,  in  order  to  widen 


markets,  ease  production  controls,  and  help 
achieve  increased  farm  family  income. 

• Acceleration  of  production  adjustments,  in- 
cluding a large  scale  land  conservation  re- 
serve program  on  a voluntary  and  equitable 
rental  basis,  with  full  consideration  of  the 
impact  on  local  communities. 

• Continued  progress  in  the  wise  use  and 
conservation  of  water  and  soil  resources. 

• Use  of  marketing  agreements  and  orders, 
and  other  marketing  devices,  when  approved 
by  producers,  to  assist  in  the  orderly  market- 
ing of  crops,  thus  enabling  farmers  to 
strengthen  their  bargaining  power. 

• Stepped-up  research  to  reduce  production 
costs  and  to  cut  distribution  costs. 

• Strengthening  of  the  educational  programs 
of  the  U.  S.  Department  of  Agriculture  and 
the  Land-Grant  institutions. 

• Improvement  of  credit  facilities  for  financ- 
ing the  capital  needs  of  modern  farming. 

• Encouragement  of  farmer  owned  and  op- 
erated cooperatives  including  rural  electric 
and  telephone  facilities. 

• Expansion  of  the  Rural  Development  Pro- 
gram to  help  low-income  farm  families  not 
only  through  better  farming  methods,  but 
also  through  opportunities  for  vocational 
training,  more  effective  employment  services, 
and  creation  of  job  opportunities  through  en- 
couragement of  local  industrialization. 

• Continuation  and  further  improvement  of 
the  Great  Plains  Program. 

• Legislative  action  for  programs  now  sched- 
uled to  expire  for  the  school  milk  program, 
wool,  and  sugar,  including  increased  sugar 
acreage  to  domestic  areas. 

• Free  movement  in  interstate  commerce  of 
agricultural  commodities  meeting  federal 
health  standards. 

• To  prevent  dumping  of  agricultural  im- 
ports upon  domestic  markets. 

To  assure  the  American  farmer  a more  direct 
voice  in  his  own  destiny,  we  pledge: 

• To  select  an  official  committee  of  farmers 
and  ranchers,  on  a regional  basis,  broadly 


OCTOBER  I960— VOL.  30,  NO.  4 


223 


THE  ASSOCIATION  FORUM 


representative  of  American  agriculture, 
whose  function  will  be  to  recommend  to  the 
President  guidelines  for  improving  the  opera- 
tion of  government  farm  programs. 


Nafural  Resources 

A strong  and  growing  economy  requires 
vigorous  and  persistent  attention  to  wise  con- 
servation and  sound  development  of  all  our 
resources.  Teamwork  between  federal,  state 
and  private  entities  is  essential  and  should  be 
continued.  It  has  resulted  in  sustained  con- 
servation and  resource  development  programs 
on  a scale  unmatched  in  our  history. 

The  past  seven  years  of  Republican  leader- 
ship have  seen  the  development  of  more 
power  capacity,  flood  control,  irrigation,  fish 
and  wildlife  projects,  recreational  facilities, 
and  associated  multi-purpose  benefits  than 
during  any  previous  administration  in  his- 
tory. The  proof  is  visible  in  the  forests  and 
waters  of  the  land  and  in  Republican  initia- 
tion of  and  support  for  the  Upper  Watershed 
Program  and  the  Small  Reclamation  Projects 
Act.  It  is  clear,  also,  in  the  results  of  con- 
tinuing administration-encouraged  forest 
management  practices  which  have  brought, 
for  the  first  time,  a favorable  balance  between 
the  growth  and  cutting  of  America’s  trees. 

Our  objective  is  for  further  growth,  greater 
strength,  and  increased  utilization  in  each 
great  area  of  resource  use  and  development. 

We  pledge: 

• Use  of  the  community  watershed  as  the 
basic  natural  unit  through  which  water  re- 
source, soil,  and  forest  management  programs 
may  best  be  developed,  with  interstate  com- 
pacts encouraged  to  handle  regional  aspects 
without  federal  domination. 

• Development  of  new  water  resource  proj- 
ects throughout  the  nation. 

• Support  of  the  historic  policy  of  Congress 
in  preserving  the  integrity  of  the  several 
States  to  govern  water  rights. 

• Continued  federal  support  for  Republican- 


initiated  research  and  demonstration  projects 
which  will  supply  fresh  water  from  salt  and 
brackish  water  sources. 

© Necessary  measures  for  preservation  of  our 
domestic  fisheries. 

• Continued  forestry  conservation  with  ap- 
propriate sustained  yield  harvesting,  thus  in- 
creasing jobs  for  people  and  increasing  reve- 
nue. 

• To  observe  the  “preference  clause”  in  mar- 
keting federal  power. 

• Support  of  the  basic  principles  of  reclama- 
tion. 

• Recognition  of  urban  and  industrial  de- 
mands by  making  available  to  states  and  lo- 
cal governments,  federal  lands  not  needed  for 
national  programs. 

Full  use  and  preservation  of  our  great  out- 
doors are  pledged  in: 

• Completion  of  the  “Mission  66”  for  the  im- 
provement of  National  Park  areas  as  well  as 
sponsorship  of  a new  “Mission  76”  program 
to  encourage  establishment  and  rehabilitation 
of  local,  state,  and  regional  parks,  to  provide 
adequate  recreational  facilities  for  our  ex- 
panding population. 

• Continued  support  of  the  effort  to  keep 
our  great  out-of-doors  beautiful,  green,  and 
clean. 

® Establishment  of  a citizens  board  of  con- 
servation, resource  and  land  management  ex- 
perts to  inventory  those  federal  lands  now 
set  aside  for  a particular  purpose;  to  study 
the  future  needs  of  the  nation  for  parks,  sea- 
shores, and  wildlife  and  other  recreational 
areas;  and  to  study  the  possibility  of  restor- 
ing lands  not  needed  for  a federal  program. 

Minerals,  metals,  fuels,  also  call  for  carefully 
considered  actions  in  view  of  the  repeated 
failure  of  Democratic-controlled  Congresses 
to  enact  any  long-range  minerals  legislation. 
Republicans,  therefore,  pledge: 

« Long-range  minerals  and  fuels  planning 
and  programming,  including  increased  coal 
research. 


224 


J.  M.  A.  ALABAMA 


THE  ASSOCIATION  FORUM 


• Assistance  to  mining  industries  in  bridg- 
ing the  gap  between  peak  defense  demands 
and  anticipated  peacetime  demands. 

• Continued  support  for  federal  financial  as- 
sistance and  incentives  under  our  tax  laws 
to  encourage  exploration  for  domestic  sources 
of  minerals  and  metals,  with  reasonable  de- 
pletion allowances. 

To  preserve  our  fish  and  voildlife  heritage,  we 
pledge: 

« Legislation  to  authorize  exchange  of  lands 
between  state  and  federal  governments  to 
adapt  programs  to  changing  uses  and  habits. 

• Vigorous  implementation  of  long-range 
programs  for  fish  and  wildlife. 


Government  Finance 

To  build  a better  America  with  broad  na- 
tional purposes  such  as  high  employment,  vig- 
orous and  steady  economic  growth,  and  a de- 
pendable currency,  responsible  management 
of  our  federal  finances  is  essential.  Even 
more  important,  a sound  economy  is  vital  to 
national  security.  While  leading  Democrats 
charge  us  with  a “budget  balancing”  mental- 
ity, their  taunts  really  reflect  their  frustra- 
tion over  the  people’s  recognition  that  as  a 
nation  we  must  live  within  our  means.  Gov- 
ernment that  is  careless  with  the  money  of 
its  citizens  is  careless  with  their  future. 

Because  we  are  concerned  about  the  well- 
being of  people,  we  are  concerned  about  pro- 
tecting the  value  of  their  money.  To  this 
end,  we  Republicans  believe  that: 

• Every  government  expenditure  must  be 
tested  by  its  contribution  to  the  general  wel- 
fare, not  to  any  narrow  interest  group. 

• Except  in  times  of  war  or  economic  ad- 
versity, expenditures  should  be  covered  by 
revenues. 

• We  must  work  persistently  to  reduce,  not 
to  increase,  the  national  debt,  which  imposes 
a heavy  economic  burden  on  every  citizen. 

• Our  tax  structure  should  be  improved  to 
provide  greater  incentives  to  economic  prog- 


ress, to  make  it  fair  and  equitable,  and  to 
maintain  and  deserve  public  acceptance. 

• We  must  resist  assaults  upon  the  independ- 
ence of  the  Federal  Reserve  System;  we  must 
strengthen,  not  weaken,  the  ability  of  the 
Federal  Reserve  System  and  the  Treasury 
Department  to  exercise  effective  control  over 
money  and  credit  in  order  better  to  combat 
both  deflation  and  inflation  that  retard  eco- 
nomic growth  and  shrink  people’s  savings  and 
earnings. 

• In  order  of  priority,  federal  revenues 
should  be  used:  first,  to  meet  the  needs  of 
national  security;  second,  to  fulfill  the  legiti- 
mate and  urgent  needs  of  the  nation  that  can- 
not be  met  by  the  States,  local  governments 
or  private  action;  third,  to  pay  down  on  the 
national  debt  in  good  times;  finally,  to  im- 
prove our  tax  structure. 

National  security  and  other  essential  needs 
will  continue  to  make  enormous  demands  up- 
on public  revenues.  It  is  therefore  imperative 
that  we  weigh  carefully  each  demand  for  a 
new  federal  expenditure.  The  federal  gov- 
ernment should  undertake  not  the  most  things 
nor  the  least  things,  but  the  right  things. 

Achieving  this  vital  purpose  demands: 

• That  Congress,  in  acting  on  new  spending 
bills,  have  figures  before  it  showing  the  cu- 
mulative effect  of  its  actions  on  the  total 
budget. 

• That  spending  commitments  for  future 
years  be  clearly  listed  in  each  budget,  so  that 
the  effect  of  built-in  expenditure  programs 
may  be  recognized  and  evaluated. 

• That  the  President  be  empowered  to  veto 
individual  items  in  authorization  and  appro- 
priation bills. 

• That  increasing  efforts  be  made  to  extend 
business-like  methods  to  government  opera- 
tions, particularly  in  purchasing  and  supply 
activities,  and  in  personnel. 


OCTOBER  I960— VOL.  30,  NO.  4 


225 


THE  ASSOCIATION  FORUM 


Government  Administration 

The  challenges  of  our  time  test  the  very 
organization  of  democracy.  They  put  on  trial 
the  capacity  of  free  government  to  act  quick- 
ly, wisely,  resolutely.  To  meet  these  chal- 
lenges: 

• The  President  must  continue  to  be  able  to 
reorganize  and  streamline  executive  opera- 
tions to  keep  the  executive  branch  capable  of 
responding  effectively  to  rapidly  changing 
conditions  in  both  foreign  and  domestic  fields. 
The  Eisenhower-Nixon  Administration  did  so 
by  creating  a new  Department  of  Health,  Ed- 
ucation and  Welfare,  by  establishing  the  Na- 
tional Aeronautics  and  Space  Agency  and  the 
Federal  Aviation  Agency,  and  by  reorganiza- 
tions of  the  Defense  Department. 

• Two  top  positions  should  be  established  to 
assist  the  President  in,  (1)  the  entire  field  of 
National  Security  and  International  Affairs, 
and,  (2)  Governmental  Planning  and  Man- 
agement, particularly  in  domestic  affairs. 

• We  must  undertake  further  reorganization 
of  the  Defense  Department  to  achieve  the 
most  effective  unification  of  defense  planning 
and  command. 

• Improved  conflict-of-interest  laws  should 
be  enacted  for  vigilant  protection  of  the  pub- 
lic interest  and  to  remove  deterrents  to  gov- 
ernmental service  by  our  most  able  citizens. 

• The  federal  government  must  constantly 
strengthen  its  career  service  and  must  be 
truly  progressive  as  an  employer.  Govern- 
ment employment  must  be  a vocation  deserv- 
ing of  high  public  respect.  Common  sense 
demands  continued  improvements  in  employ- 
ment, training  and  promotion  practices  based 
on  merit,  effective  procedures  for  dealing 
with  employment  grievances,  and  salaries 
which  are  comparable  to  those  offered  by 
private  employers. 

• As  already  practiced  by  the  Republican 
membership,  responsible  Policy  Committees 
should  be  elected  by  each  party  in  each  house 
of  Congress.  This  would  provide  a mechan- 
ism for  meetings  of  party  Congressional  lead- 


ers with  the  President  when  circumstances 
demand. 

• Needed  federal  judgeships,  appointed  on 
the  basis  of  the  highest  qualifications  and 
without  limitation  to  a single  political  party, 
should  be  created  to  expedite  administration 
of  justice  in  federal  courts. 

• The  remarkable  growth  of  the  Post  Office 
since  1952  to  serve  an  additional  9 million 
urban  and  D/^)  million  farm  families  must  be 
continued.  The  Post  Office  must  be  contin- 
ually improved  and  placed  on  a self-sustain- 
ing basis.  Progressive  Republican  policies  of 
the  past  seven  years  have  resulted  in  reduced 
costs,  decentralization  of  postal  operations, 
liberal  pay,  fringe  benefits,  improved  work- 
ing conditions,  streamlined  management  and 
improved  service. 

Vigorous  state  and  local  governments  are 
a vital  part  of  our  federal  union.  The  federal 
government  should  leave  to  state  and  local 
governments  those  programs  and  problems 
which  they  can  best  handle  and  tax  sources 
adequate  to  finance  them.  We  must  continue 
to  improve  liaison  between  federal,  state  and 
local  governments.  We  believe  that  the  fed- 
eral government,  when  appropriate,  should 
render  significant  assistance  in  dealing  with 
our  urgent  problems  of  urban  growth  and 
change.  No  vast  new  bureaucracy  is  needed 
to  achieve  this  objective. 

We  favor  a change  in  the  Electoral  College 
system  to  give  every  voter  a fair  voice  in 
presidential  elections. 

We  condemn  bigotry,  smear  and  other  un- 
fair tactics  in  political  campaigns.  We  favor 
realistic  and  effective  safeguards  against  di- 
verting non-political  funds  to  partisan  politi- 
cal purposes. 

Republicans  will  continue  to  work  for  Con- 
gressional representation  and  self-govern- 
ment for  the  District  of  Columbia  and  also 
support  the  constitutional  amendment  grant- 
ing suffrage  in  national  elections. 

We  support  the  right  of  the  Puerto  Rican 
people  to  achieve  statehood,  whenever  they 
freely  so  determine.  We  support  the  right 
of  the  people  of  the  Virgin  Islands  to  an 


226 


J.  M.  A.  ALABAMA 


THE  ASSOCIATION  FORUM 


elected  Governor,  national  representation  and 
suffrage,  looking  toward  eventual  statehood, 
when  qualified.  We  also  support  the  right  of 
the  people  of  Guam  to  an  elected  Governor 
and  national  representation.  These  pledges 
are  meaningful  from  the  Republican  leader- 
ship under  which  Alaska  and  Hawaii  have 
newly  entered  the  Union. 

Congress  should  submit  a constitutional 
amendment  providing  equal  rights  for  wom- 
en. 


Bducafion 

The  rapid  pace  of  international  develop- 
ments serves  to  re-emphasize  dramatically 
the  challenge  which  generations  of  Ameri- 
cans will  face  in  the  years  ahead.  We  are 
reminded  daily  of  the  crucial  importance  of 
strengthening  our  system  of  education  to  pre- 
pare our  youth  for  understanding  and  shap- 
ing the  powerful  emerging  forces  of  the  mod- 
ern world  and  to  permit  the  fullest  possible 
development  of  individual  capacities  and  po- 
tentialities. 

We  express  our  gratefulness  and  we  praise 
the  countless  thousands  of  teachers  who  have 
devoted  themselves  in  an  inspired  way  to- 
wards the  development  of  our  greatest  heri- 
tage— our  own  children — the  youth  of  the 
country. 

Education  is  not  a luxury,  nor  a gift  to  be 
bestowed  upon  ourselves  and  our  children. 
Education  is  an  investment;  our  schools  can- 
not become  second  best.  Each  person  pos- 
sesses the  right  to  education — it  is  his  birth- 
right in  a free  Republic. 

Primary  responsibility  for  education  must 
remain  with  the  local  community  and  state. 
The  federal  government  should  assist  selec- 
tively in  strengthening  education  without  in- 
terfering with  full  local  control  of  schools. 
One  objective  of  such  federal  assistanc* 
should  be  to  help  equalize  educational  oppor- 
tunities. Under  the  Eisenhower-Nixon  Ad- 
ministration, the  federal  government  will 


spend  more  than  a billion  dollars  in  1960  to 
strengthen  American  education. 

We  commend  the  objective  of  the  Repub- 
lican Administration  in  sponsoring  the  Na- 
tional Defense  Education  Act  to  stimulate 
improvement  of  study  and  teaching  in  select- 
ed fields  at  the  local  level. 

Toward  the  goal  of  fullest  possible  educa- 
tional opportunity  for  every  American,  we 
pledge  these  actions; 

• Federal  support  to  the  primary  and  sec- 
ondary schools  by  a program  of  federal  aid 
for  school  construction — pacing  it  to  the  real 
needs  of  individual  school  districts  in  states 
and  territories,  and  requiring  state  approval 
and  participation. 

• Stimulation  of  actions  designed  to  update 
and  strengthen  vocational  education  for  both 
youth  and  adults. 

• Support  of  efforts  to  make  adequate  li- 
brary facilities  available  to  all  our  citizens. 

• Continued  support  of  programs  to 
strengthen  basic  research  in  education;  to 
discover  the  best  methods  for  helping  handi- 
capped, retarded,  and  gifted  children  to  rea- 
lize their  highest  potential. 

The  federal  government  can  also  play  a 
part  in  stimulating  higher  education.  Con- 
structive action  would  include: 

• The  federal  program  to  assist  in  construc- 
tion of  college  housing. 

• Extension  of  the  federal  student  loan  pro- 
gram and  graduate  fellowship  program. 

• Consideration  of  means  through  tax  laws 
to  help  offset  tuition  costs. 

• Continued  support  of  the  East-West  Cen- 
ter for  cultural  and  technical  interchange  in 
Hawaii  for  the  purpose  of  strengthening  our 
relationship  with  the  peoples  of  the  Pacific 
world. 

• Federal  matching  grants  to  help  states  fi- 
nance the  cost  of  state  surveys  and  inven- 
tories of  the  status  and  needs  of  their  school 
systems. 

Provision  should  be  made  for  continuous 
attention  to  education  at  all  levels  by  the 


OCTOBER  I960— VOL.  30,  NO.  4 


227 


THE  ASSOCIATION  FORUM 


creation  of  a permanent,  top-level  commission 
to  advise  the  President  and  the  Secretary  of 
Health,  Education  and  Welfare,  constantly 
striving  to  focus  the  interest  of  each  citizen 
on  the  quality  of  our  education  at  every  level, 
from  primary  through  post-graduate,  and  for 
every  age  group  from  children  to  adults. 

We  are  aware  of  the  fact  that  there  is  a 
temporary  shortage  of  classrooms  for  our 
elementary  and  secondary  schools  in  a limited 
number  of  states.  But  this  shortage,  due  to 
the  vigilant  action  of  state  legislatures  and 
local  school  boards,  is  not  increasing,  but  is 
decreasing. 

We  shall  use  our  full  efforts  in  all  the  states 
of  the  Union  to  have  these  legislatures  and 
school  boards  augment  their  present  efforts 
to  the  end  that  this  temporary  shortage  may 
be  eliminated  and  that  every  child  in  this 
country  shall  have  the  opportunity  to  obtain 
a good  education.  The  respective  states  as 
a permanent  program  can  shoulder  this  long- 
standing and  cherished  responsibility  easier 
than  can  the  federal  government  with  its 
heavy  indebtedness. 

We  believe  moreover  that  any  large  plan 
of  federal  aid  to  education,  such  as  direct 
contributions  to  or  grants  for  teachers  sal- 
aries can  only  lead  ultimately  to  federal 
domination  and  control  of  our  schools  to 
which  we  are  unalterably  opposed. 

In  the  words  of  President  Eisenhower,  “Ed- 
ucation best  fulfills  its  high  purpose  when 
responsibility  for  education  is  kept  close  to 
the  people  it  serves — when  it  is  rooted  in  the 
homes,  nurtured  in  the  community  and  sus- 
tained by  a rich  variety  of  public,  private 
and  individual  resources.  The  bond  linking 
home  and  school  and  community — the  re- 
sponsiveness of  each  to  the  needs  of  the  oth- 
ers— is  a precious  asset  of  American  educa^ 
tion.” 


Science  and  Technology 

Much  of  America’s  future  depends  upon  the 
inquisitive  mind,  freely  searching  nature  for 


ways  to  conquer  disease,  poverty  and  grinding 
physical  demands,  and  for  knowledge  of  space 
and  the  atom. 

We  Republicans  express  our  profound 
gratitude  to  the  great  scientists  and  engineers 
of  our  country,  both  in  and  out  of  government, 
for  the  remarkable  progress  they  have  made. 
Reliable  evidence  indicates,  all  areas  of  sci- 
entific knowledge  considered,  that  our  coun- 
try has  been,  is,  and  under  our  system  of  free 
inquiry,  will  continue  to  be  the  greatest  arse- 
nal and  reservoir  of  effective  scientific  knowl- 
edge in  the  world. 

We  pledge  our  continued  leadership  in  ev- 
ery field  of  science  and  technology,  earth- 
bound  as  well  as  spatial,  to  assure  a citadel 
of  liberty  from  which  the  fruits  of  freedom 
may  be  carried  to  all  people. 

Our  continuing  and  great  national  need  is 
for  basic  research — a wellspring  of  knowl- 
edge and  progress.  Government  must  con- 
tinue to  take  a responsible  role  in  science  to 
assure  that  worthwhile  endeavors  of  nation- 
al significance  are  not  retarded  by  practical 
limitations  of  private  and  local  support.  This 
demands  from  all  Americans  the  intellectual 
leadership  and  understanding  so  necessary 
for  these  creative  endeavors  and  an  equal  un- 
derstanding by  our  scientists  and  technicians 
of  the  needs  and  hopes  of  mankind. 

We  believe  the  federal  roles  in  research  to 
be  in  the  area  of  (1)  basic  research  which 
industry  cannot  be  reasonably  expected  to 
pursue,  and  (2)  applied  research  in  fields  of 
prime  national  concern  such  as  national  de- 
fense, exploration  and  use  of  space,  public 
health,  and  better  common  use  of  all  natural 
resources,  both  human  and  physical.  We 
endorse  the  contracting  by  government 
agencies  for  research  and  urge  allowance 
for  reasonable  charges  for  overhead  and 
management  in  connection  therewith. 

The  vigor  of  American  science  and  tech- 
nology may  best  be  inspired  by; 

• An  environment  of  freedom  and  public  un- 
derstanding in  which  intellectual  achieve- 
ment and  scientific  research  may  flourish. 


228 


J.  M.  A.  ALABAMA 


THE  ASSOCIATION  FORUM 


• A decentralization  of  research  into  as  many 
centers  of  creativity  as  possible. 

• The  encouragement  of  colleges  and  uni- 
versities, private  enterprise,  and  foundations 
as  a growing  source  of  new  ideas  and  new 
applications. 

• Opportunity  for  scientists  and  engineers, 
in  and  out  of  government,  to  pursue  their 
search  with  utmost  aggressiveness. 

• Continuation  of  the  advisory  committee 
to  represent  the  views  of  the  scientific  com- 
munity to  the  President  and  of  the  Federal 
Council  for  Science  and  Technology  to  foster 
coordination  in  planning  and  execution. 

• Continued  expansion  of  the  Eisenhower- 
Nixon  Atoms-for-Peace  program  and  a con- 
stant striving,  backed  by  scientific  advice, 
for  international  agreement  for  peaceful  and 
cooperative  exploration  and  use  of  space. 


Human  Needs 

The  ultimate  objective  of  our  free  society 
and  of  an  ever-growing  economy  is  to  en- 
able the  individual  to  pursue  a life  of  dignity 
and  to  develop  his  own  capacities  to  his  maxi- 
mum potential. 

Government’s  primary  role  is  to  help  pro- 
vide the  environment  within  which  the  indi- 
vidual can  seek  his  own  goals.  In  some  areas 
this  requires  federal  action  to  supplement  in- 
dividual, local  and  state  initiative.  The  Re- 
publican Party  has  acted  and  will  act  decis- 
ively, compassionately,  and  with  deep  human 
understanding  in  approaching  such  problems 
as  those  of  the  aged,  the  infirm,  the  mentally 
ill,  and  the  needy. 

This  is  demonstrated  by  the  significant  in- 
crease in  social  security  coverage  and  bene- 
fits as  a result  of  recommendations  made  by 
the  Eisenhower-Nixon  Administration.  As  a 
result  of  these  recommendations  and  normal 
growth,  14  million  persons  are  receiving  bene- 
fits today  compared  to  five  million  in  1952, 
and  benefit  payments  total  $10.3  billion  as 
compared  to  $2.5  billion  in  1952.  In  addition, 
there  have  been  increases  in  payments  to 


those  on  public  assistance,  both  for  their  basic 
needs  and  for  their  health  and  medical  care; 
and  a broad  expansion  in  our  federal-state 
program  for  restoring  disabled  persons  to  use- 
ful lives — an  expansion  which  has  accom- 
plished the  rehabilitation  of  over  half  a mil- 
lion persons  during  this  Administration. 

New  needs,  however,  are  constantly  arising 
in  our  highly  complex,  interdependent,  and 
urbanized  society. 

Older  Citizens 

To  meet  the  needs  of  the  aging,  we  pledge: 

• Expansion  of  coverage,  and  liberalization 
of  selected  social  security  benefits  on  a basis 
which  would  maintain  the  fiscal  integrity  of 
the  system. 

• Support  of  federal-state  grant  programs  to 
improve  health,  welfare  and  rehabilitation 
services  for  the  handicapped  older  persons 
and  to  improve  standards  of  nursing  home 
care  and  care  and  treatment  facilities  for  the 
chronically  and  mentally  ill. 

® Support  of  programs  that  will  persuade 
and  encourage  the  nation  to  utilize  fully  the 
skills,  wisdom  and  experience  of  older  citi- 
zens. 

• Prompt  consideration  of  recommendations 
by  the  White  House  Conference  on  Aging 
called  by  the  President  for  January,  1961. 

Health  Aid 

Development  of  a health  program  that  will 
provide  the  aged  needing  it,  on  a sound  fiscal 
basis  and  through  a contributory  system,  pro- 
tection against  burdensome  costs  of  health 
care.  Such  a program  should; 

• Provide  the  beneficiaries  with  the  option 
of  purchasing  private  health  insurance — a 
vital  distinction  between  our  approach  and 
Democratic  proposals  in  that  it  would  en- 
courage commercial  carriers  and  voluntary 
insurance  organizations  to  continue  their  ef- 
forts to  develop  sound  coverage  plans  for  the 
senior  population. 

• Protect  the  personal  relationship  of  pa- 
tient and  physician. 

• Include  state  participation. 

For  the  needs  which  individuals  of  all  age 


OCTOBER  I960— VOL.  30,  NO.  4 


229 


THE  ASSOCIATION  FORUM 


groups  cannot  meet  by  themselves,  we  pro- 
pose: 

• Removing  the  arbitrary  50-year  age  re- 
quirement under  the  disability  insurance  pro- 
gram while  amending  the  law  also  to  provide 
incentives  for  rehabilitated  persons  to  return 
to  useful  work. 

• A single,  federal  assistance  grant  to  each 
state  for  aid  to  needy  persons  rather  than 
dividing  such  grants  into  specific  categories. 

• A strengthened  federal-state  program  to 
rehabilitate  the  estimated  200,000  persons 
who  annually  could  become  independent  af- 
ter proper  medical  services  and  occupational 
training. 

• A new  federal-state  program,  for  handi- 
capped persons  completely  dependent  on  oth- 
ers, to  help  them  meet  their  needs  for  per- 
sonal care. 

Juvenile  Delinquency 
The  Federal  Government  can  and  should 
help  state  and  local  communities  combat  ju- 
venile delinquency  by  inaugurating  a grant 
program  for  research,  demonstration,  and 
training  projects  and  by  placing  greater  em- 
phasis on  strengthening  family  life  in  all  wel- 
fare programs  for  which  it  shares  responsi- 
bility. 

Veterans 

We  believe  that  military  service  in  the  de- 
fense of  our  Republic  against  aggressors  who 
have  sought  to  destroy  the  freedom  and  digni- 
ty of  man  imposes  upon  the  nation  a special 
responsibility  to  those  who  have  served.  To 
meet  this  responsibility,  we  pledge: 

• Continuance  of  the  Veterans  Administra- 
tion as  an  independent  agency. 

• The  highest  possible  standard  of  medical 
care  with  increasing  emphasis  on  rehabilita- 
tion. 

Indian  Affairs 

As  recently  as  1953,  thirty  per  cent  of  Indian 
school-age  children  were  unable  to  obtain  an 
education.  Through  Republican  efforts,  this 
fall,  for  the  first  time  in  history,  every  eligible 
Indian  child  will  be  able  to  attend  an  elemen- 
tary school.  Having  accomplished  this,  we 


will  now  accelerate  our  efforts  to  open  up 
both  secondary  and  higher  education  oppor- 
tunities for  every  qualified  Indian  youth. 

As  a result  of  a stepped-up  health  program 
there  has  been  a marked  decrease  in  death 
rates  from  tuberculosis  and  in  the  infant  mor- 
tality rate.  Also  substantial  progress  has 
been  made  in  the  modernization  of  health 
facilities.  We  pledge  continued  progress  in 
this  area. 

We  are  opposed  to  precipitous  termination 
of  the  federal  Indian  trusteeship  responsibili- 
ty, and  pledge  not  to  support  any  termination 
plan  for  any  tribe  which  has  not  approved 
such  action. 

Housing 

Despite  noteworthy  accomplishments,  stub- 
born and  deep-seated  problems  stand  in  the 
way  of  achieving  the  national  objective  of 
a decent  home  in  a suitable  environment  for 
every  American.  Recognizing  that  the  fed- 
eral government  must  help  provide  the  eco- 
nomic climate  and  incentives  which  make  this 
objective  obtainable,  the  Republican  Party 
will  vigorously  support  the  following  steps, 
all  designed  to  supplement  and  not  supplant 
private  initiative. 

• Continued  effort  to  clear  slums,  and  pro- 
mote rebuilding,  rehabilitation,  and  conser- 
vation of  our  cities. 

® New  programs  to  stimulate  development 
of  specialized  types  of  housing,  such  as  those 
for  the  elderly  and  for  nursing  homes. 

• A program  of  research  and  demonstration 
aimed  at  finding  ways  to  reduce  housing 
costs,  including  support  of  efforts  to  mod- 
ernize and  improve  local  building  codes. 

• Adequate  authority  for  the  federal  hous- 
ing agencies  to  assist  the  flow  of  mortgage 
credit  into  private  housing,  with  emphasis  on 
homes  for  middle-  and  lower-income  families 
and  including  assistance  in  urban  residential 
areas. 

• A stepped-up  program  to  assist  in  urban 
planning,  designed  to  assure  far-sighted  and 


230 


J.  M.  A.  ALABAMA 


THE  ASSOCIATION  FORUM 


wise  use  of  land  and  to  coordinate  mass  trans- 
portation and  other  vital  facilities  in  our 
metropolitan  areas. 

Health 

There  has  been  a five-fold  increase  in  gov- 
ernment-assisted medical  research  during  the 
last  six  years.  We  pledge: 

• Continued  federal  support  for  a sound  re- 
search program  aimed  at  both  the  prevention 
and  cure  of  diseases,  and  intensified  efforts  to 
secure  prompt  and  effective  application  of 
the  results  of  research.  This  will  include  em- 
phasis on  mental  illness. 

• Support  of  international  health  research 
programs. 

We  face  serious  personnel  shortages  in  the 
health  and  medical  fields.  We  pledge: 

• Federal  help  in  new  programs  to  build 
schools  of  medicine,  dentistry,  and  public 
health  and  nursing,  and  financial  aid  to  stu- 
dents in  those  fields. 

We  are  confronted  with  major  problems  in 
the  field  of  environmental  health.  We  pledge: 

• Strengthened  federal  enforcement  powers 
in  combatting  water  pollution  and  additional 
resources  for  research  and  demonstration 
projects.  Federal  grants  for  the  construction 
of  waste  disposal  plants  should  be  made  only 
when  they  make  an  identifiable  contribution 
to  clearing  up  polluted  streams. 

• Federal  authority  to  identify,  after  appro- 
priate hearings,  air  pollution  problems  and  to 
recommend  proposed  solutions. 

• Additional  resources  for  research  and 
training  in  the  field  of  radiological  medicine. 

Protection  of  Consumers 
In  safeguarding  the  health  of  the  nation  the 
Eisenhower-Nixon  Administration’s  initiative 
has  resulted  in  doubling  the  resources  of  the 
Food  and  Drug  Administration  and  in  giving 
it  new  legal  weapons.  More  progress  has 
been  made  during  this  period  in  protecting 
consumers  against  harmful  food,  drugs,  and 
cosmetics  than  in  any  other  time  in  our  his- 
tory. We  will  continue  to  give  strong  sup- 
port to  this  consumer-protection  program. 

OCTOBER  I960— VOL.  30,  NO.  4 


Civil  Rights 

This  nation  was  created  to  give  expression, 
validity  and  purpose  to  our  spiritual  heritage 
— the  supreme  worth  of  the  individual.  In 
such  a nation — a nation  dedicated  to  the 
proposition  that  all  men  are  created  equal — 
racial  discrimination  has  no  place.  It  can 
hardly  be  reconciled  with  a Constitution  that 
guarantees  equal  protection  under  law  to  all 
persons.  In  a deeper  sense,  too,  it  is  immoral 
and  unjust.  As  to  those  matters  within  reach 
of  political  action  and  leadership,  we  pledge 
ourselves  unreservedly  to  its  eradication. 

Equality  under  law  promises  more  than  the 
equal  right  to  vote  and  transcends  mere  re- 
lief from  discrimination  by  government.  It 
becomes  a reality  only  when  all  persons  have 
equal  opportunity,  without  distinction  of  race, 
religion,  color,  or  national  origin,  to  acquire 
the  essentials  of  life — housing,  education  and 
employment.  The  Republican  Party — the 
party  of  Abraham  Lincoln — from  its  very  be- 
ginning has  striven  to  make  this  promise  a 
reality.  It  is  today,  as  it  was  then,  unequivo- 
cally dedicated  to  making  the  greatest  amount 
of  progress  toward  that  objective. 

We  recognize  that  discrimination  is  not  a 
problem  localized  in  one  area  of  the  country, 
but  rather  a problem  that  must  be  faced  by 
North  and  South  alike.  Nor  is  discrimination 
confined  to  the  discrimination  against  Ne- 
groes. Discrimination  in  many,  if  not  all, 
areas  of  the  country  on  the  basis  of  creed  or 
national  origin  is  equally  insidious.  Further 
we  recognize  that  in  many  communities  in 
which  a century  of  custom  and  tradition  must 
be  overcome  heartening  and  commendable 
progress  has  been  made. 

The  Republican  Party  is  proud  of  the  civil 
rights  record  of  the  Eisenhower  Administra- 
tion. More  progress  has  been  made  during 
the  past  eight  years  than  in  the  preceding  80 
years.  We  acted  promptly  to  end  discrimi- 
nation in  our  nation’s  capital.  Vigorous  exec- 
utive action  was  taken  to  complete  swiftly  the 
desegregation  of  the  armed  forces,  veterans’ 
hospitals,  navy  yards,  and  other  federal  estab- 
lishments. 

23 1 


THE  ASSOCIATION  FORUM 


We  supported  the  position  ot  the  Negro 
school  children  before  the  Supreme  Court. 
We  believe  the  Supreme  Court  school  deci- 
sion should  be  carried  out  in  accordance  with 
the  mandate  of  the  Court. 

Although  the  Democratic-controlled  Con- 
gress watered  them  down,  the  Republican 
Administration’s  recommendations  resulted 
in  significant  and  effective  civil  rights  legis- 
lation in  both  1957  and  1960 — the  first  civil 
rights  statutes  to  be  passed  in  more  than  80 
years. 

Hundreds  of  Negroes  have  already  been 
registered  to  vote  as  a result  of  Department 
of  Justice  action,  somie  in  counties  where 
Negroes  did  not  vote  before.  The  new  law 
will  soon  make  it  possible  for  thousands  and 
thousands  of  Negroes  previously  disenfran- 
chised to  vote. 

By  executive  order,  a committee  for  the 
elimination  of  discrimination  in  government 
employment  has  been  reestablished  with 
broadened  authority. 

The  President’s  Committee  on  Government 
Contracts,  under  the  chairmanship  of  Vice 
President  Nixon  has  become  an  impressive 
force  for  the  elimination  of  discriminatory 
employment  practices  of  private  companies 
that  do  business  with  the  government. 

Other  important  achievements  include  ini- 
tial steps  toward  the  elimination  of  segrega- 
tion in  federally-aided  housing;  the  estab- 
lishment of  the  Civil  Rights  Division  of  the 
Department  of  Justice,  which  enforces  federal 
civil  rights  laws;  and  the  appointment  of  the 
bi-partisan  Civil  Rights  Commission,  which 
has  prepared  a significant  report  that  lays 
the  groundwork  for  further  legislative  action 
and  progress. 

The  Republican  record  is  a record  of  prog- 
ress— not  merely  promises.  Nevertheless,  we 
recognize  that  much  remains  to  be  done. 

Each  of  the  following  pledges  is  practical 
and  within  realistic  reach  of  accomplishment. 
They  are  serious — not  cynical — pledges  made 
to  result  in  maximum  progress. 


1.  Voting.  We  pledge; 

• Continued  vigorous  enforcement  of  the 
civil  rights  laws  to  guarantee  the  right  to 
vote  to  all  citizens  in  all  areas  of  the  country. 

• Legislation  to  provide  that  the  completion 
of  six  primary  grades  in  a state  accredited 
school  is  conclusive  evidence  of  literacy  for 
voting  purposes. 

2.  Public  Schools.  We  pledge: 

• The  Department  of  Justice  will  continue 
its  vigorous  support  of  court  orders  for  school 
desegregation.  Desegregation  suits  now 
pending  involve  at  least  39  school  districts. 
Those  suits  and  others  already  concluded  will 
affect  most  major  cities  in  which  school  segre- 
gation is  being  practiced. 

• It  will  use  the  new  authority  provided  by 
the  Civil  Rights  Act  of  1960  to  prevent  ob- 
struction of  court  orders. 

• We  will  propose  legislation  to  authorize 
the  Attorney  General  to  bring  actions  for 
school  desegregation  in  the  name  of  the 
United  States  in  appropriate  cases,  as  when 
economic  coercion  or  threat  of  physical  harm 
is  used  to  deter  persons  from  going  to  court 
to  establish  their  rights. 

• Our  continuing  support  of  the  President’s 
proposal,  to  extend  federal  aid  and  technical 
assistance  to  schools  which  in  good  faith  at- 
tempted to  desegregate. 

We  oppose  the  pretense  of  fixing  a target 
date  3 years  from  now  for  the  mere  submis- 
sion of  plans  for  school  desegregation.  Slow- 
moving  school  districts  would  construe  it  as  a 
three-year  moratorium  during  which  progress 
would  cease,  postponing  until  1963  the  legal 
process  to  enforce  compliance.  We  believe 
that  each  of  the  pending  court  actions  should 
proceed  as  the  Supreme  Court  has  directed 
and  that  in  no  district  should  there  be  any 
such  delay. 

3.  Employment.  We  pledge: 

• Continued  support  for  legislation  to  estab- 
lish a Commission  on  Equal  Job  Opportunity 
to  make  permanent  and  to  expand  with  legis- 
lative backing  the  excellent  work  being  per- 
formed by  the  President’s  Committee  on  Gov- 
ernment Contracts. 


232 


J.  M.  A.  ALABAMA 


THE  ASSOCIATION  FORUM 


• Appropriate  legislation  to  end  the  discrimi- 
natory membership  practices  of  some  labor 
union  locals,  unless  such  practices  are  eradi- 
cated promptly  by  the  labor  unions  them- 
selves. 

• Use  of  the  full-scale  review  of  existing 
state  laws,  and  of  prior  proposals  for  federal 
legislation,  to  eliminate  discrimination  in  em- 
ployment now  being  conducted  by  the  Civil 
Rights  Commission,  for  guidance  in  our  ob- 
jective of  developing  a Federal-State  pro- 
gram in  the  employment  area. 

• Special  consideration  of  training  programs 
aimed  at  developing  the  skills  of  those  now 
working  in  marginal  agricultural  employment 
so  that  they  can  obtain  employment  in  indus- 
try, notably  in  the  new  industries  moving  in- 
to the  South. 

4.  Housing.  We  pledge: 

• Action  to  prohibit  discrimination  in  hous- 
ing constructed  with  the  aid  of  federal  sub- 
sidies. 

5.  Public  Facilities  and  Services.  We  pledge; 

• Removal  of  any  vestige  of  discrimination 
in  the  operation  of  federal  facilities  or  pro- 
cedures which  may  at  any  time  be  found. 

• Opposition  to  the  use  of  federal  funds  for 
the  construction  of  segregated  community 
facilities. 

• Action  to  ensure  that  public  transportation 
and  other  government  authorized  services 
shall  be  free  from  segregation. 

6.  Legislative  Procedure.  We  pledge; 

• Our  best  efforts  to  change  present  Rule 
22  of  the  Senate  and  other  appropriate  Con- 
gressional procedures  that  often  make  unat- 
tainable proper  legislative  implementation  of 
constitutional  guarantees. 

We  reaffirm  the  constitutional  right  to 
peaceable  assembly  to  protest  discrimination 
by  private  business  establishments.  We  ap- 
plaud the  action  of  the  businessmen  who  have 
abandoned  discriminatory  practices  in  retail 
establishments,  and  we  urge  others  to  follow 
their  example. 

Finally  we  recognize  that  civil  rights  is  a 
responsibility  not  only  of  states  and  localities; 


it  is  a national  problem  and  a national  re- 
sponsibility. The  federal  government  should 
take  the  initiative  in  promoting  inter-group 
conferences  among  those  who,  in  their  com- 
munities, are  earnestly  seeking  solutions  of 
the  complex  problems  of  desegregation — to 
the  end  that  closed  channels  of  communica- 
tion may  be  opened,  tensions  eased,  and  a co- 
operative solution  of  local  problems  may  be 
sought. 

In  summary,  we  pledge  the  full  use  of  the 
power,  resources  and  leadership  of  the  fed- 
eral government  to  eliminate  discrimination 
based  on  race,  color,  religion  or  national  ori- 
gin and  to  encourage  understanding  and  good 
will  among  all  races  and  creeds. 

Immigration 

Immigration  has  historically  been  a great 
factor  in  the  growth  of  the  United  States, 
not  only  in  numbers  but  in  the  enrichment  of 
ideas  that  immigrants  have  brought  with 
them.  This  Republican  Administration  has 
given  refuge  to  over  32,000  victims  of  Com- 
munist tyranny  from  Hungary,  ended  need- 
less delay  in  processing  applications  for  natu- 
ralization, and  has  urged  other  enlightened 
legislation  to  liberalize  existing  restrictions. 

Immigration  has  been  reduced  to  the  point 
where  it  does  not  provide  the  stimulus  to 
growth  that  it  should,  nor  are  we  fulfilling 
our  obligation  as  a haven  for  the  oppressed. 
Republican  conscience  and  Republican  policy 
require  that: 

« The  annual  number  of  immigrants  we  ac- 
cept be  at  least  doubled. 

® Obsolete  immigration  laws  be  amended  by 
abandoning  the  outdated  1920  census  data  as 
a base  and  substituting  the  1960  census. 

® The  guidelines  of  our  immigration  policy 
be  based  upon  judgment  of  the  individual 
merit  of  each  applicant  for  admission  and 
citizenship. 


OCTOBER  1960— VOL.  30,  NO.  4 


233 


THE  ASSOCIATION  FORUM 


Conclusion 

We  have  set  forth  the  program  of  the  Re- 
publican Party  for  the  government  of  the 
United  States.  We  have  written  a Party 
document,  as  is  our  duty,  but  we  have  tried 
to  refrain  from  writing  a merely  partisan  doc- 
ument. We  have  no  wish  to  exaggerate  dif- 
ferences between  ourselves  and  the  Demo- 
cratic Party;  nor  can  we,  in  conscience,  ob- 
scure the  differences  that  do  exist.  We  be- 
lieve that  the  Republican  program  is  based 
upon  a sounder  understanding  of  the  action 
and  scope  of  government.  There  are  many 
things  a free  government  cannot  do  for  its 
people  as  well  as  they  can  do  them  for  them- 
selves. There  are  some  things  no  govern- 
ment should  promise  or  attempt  to  do.  The 
functions  of  government  are  so  great  as  to 
bear  no  needless  enlargement.  We  limit  our 
proposals  and  our  pledges  to  those  areas  for 
which  the  government  of  a great  republic  can 
reasonably  be  made  responsible.  To  the  best 
of  our  ability  we  have  avoided  advocating 
measures  that  would  go  against  the  grain 
of  a free  people. 

The  history  and  composition  of  the  Repub- 
lican Party  make  it  the  natural  instrument 
for  eradicating  the  injustice  and  discrimina- 
tion in  this  country.  We  Republicans  are 
fortunate  in  being  able  to  contend  against 
these  evils,  without  having  to  contend  against 
each  other  for  the  principle. 

We  believe  that  we  see,  so  far  as  men  can 
see  through  the  obscurity  of  time  and  trouble, 
the  prudent  course  for  the  nation  in  its  hour 
of  trial.  The  Soviet  Union  has  created  an- 


other of  the  new  situations  of  peril  which  has 
been  the  Communist  record  from  the  begin- 
ning and  will  continue  to  be  until  our  strategy 
for  victory  has  succeeded.  The  speed  of  tech- 
nological change  makes  it  imperative  that  we 
measure  the  new  situations  by  their  special 
requirements  and  accelerate  as  appropriate 
our  efforts  in  every  direction,  economic  and 
military  and  political  to  deal  with  them. 

As  rapidly  as  we  perfect  the  new  genera- 
tions of  weapons  we  must  arm  ouselves  ef- 
fectively and  without  delay.  In  this  respect 
the  nation  stands  now  at  one  of  the  new  points 
of  departure.  We  must  never  allow  our  tech- 
nology, particularly  in  nuclear  and  propulsion 
fields,  to  lag  for  any  reason  until  such  time 
as  we  have  dependable  and  honest  safeguards 
of  inspection  and  control.  We  must  take  steps 
at  once  to  secure  our  position  in  this  regard 
and  at  the  same  time  we  must  intensify  our 
efforts  to  develop  better  safeguards  in  the 
field  of  disarmament. 

The  free  nations  of  the  world  must  ever 
be  rallied  to  the  cause  and  be  encouraged  to 
join  together  in  more  effective  alliances  and 
unions  strong  enough  to  meet  all  challenges 
and  sustain  the  common  effort.  It  is  urgent 
that  we  innovate  to  keep  the  initiative  for 
our  free  cause. 

We  offer  toil  and  sweat,  to  ward  off  blood 
and  tears.  We  advocate  an  immovable  re- 
sistance against  every  Communist  aggression. 
We  argue  for  a military  might  commensurate 
with  our  universal  tasks.  We  end  by  declar- 
ing our  faith  in  the  Republic  and  in  its  peo- 
ple, and  in  the  deathless  principles  of  right 
from  which  it  draws  its  moral  force. 


234 


J.  M.  A.  ALABAMA 


STRAIGHT  TALK 


At  a recent  meeting  in  Chicago,  Senator 
Mundt  (R-S.D.)  unveiled  what  v^^as  billed  un- 
officially as  “Nixon’s  farm  plan.”  The  plan 
is  to  subsidize  industry  to  embark  on  a crash 
program,  just  like  the  synthetic  rubber  pro- 
gram in  World  War  II,  and  the  current  missile 
program,  to  provide  new  markets  through  re- 
search. 

This  would  lead  to  a permanent  solution  of 

the  nation’s  farm  problem,  thinks  this  mem- 
ber of  the  Senate  Agricultural  Committee.  It 
would  emphasize  crops  for  which  there  is  a 
market  instead  of  “merely  growing  what 
comes  easy.” 

The  Vice  President,  said  Mundt,  “is  think- 
ing in  terms  of  expanding  markets  both  at 
home  and  abroad  and  in  the  whole  exciting 
and  virtually  untapped  areas  of  creating  in- 
dustrial markets  for  a large  volume  of  farm 
products.  He  is  thinking  in  terms  of  using 
incentive  payments  to  pull  acres  out  of  the 
production  of  surplus  crops  and  into  the  pro- 
duction of  crops  not  currently  in  surplus  or 
for  which  foreign,  domestic  and  industrial 
markets  can  be  developed  or  created.”  (He 
is  doubtless  “thinking  in  terms”  also  of  two 
four-year  terms  for  himself.) 

The  Vice  President,  according  to  Mundt  (no 
kin  to  madman  Mundt,  the  celebrated  car 


Reprinted  from  Farm  and  Ranch  Magazine  with 
permission  of  publisher  Tom  Anderson. 


dealer)  “envisions  an  agriculture  of  abund- 
ance and  prosperity — not  an  agriculture  of 
crippling  controls,  reduced  production  and 
security  handouts  which  prevent  farmers 
from  going  broke  but  which  also  prevent 
them  from  realizing  substantial  success.” 

Rumor  has  it  that  Nixon  will  present  his 
new  farm  plan  late  this  summer.  First,  of 
course,  he  will  have  to  decide  what  historical 
allotment  to  give  DuPont,  Ford,  Standard  Oil 
and  the  other  researchers.  A new  branch  of 
USDA,  manned  with  new  workers,  will  have 
to  be  set  up.  Quotas  and  percentage-of-parity 
support  prices  will  have  to  be  established  for 
each  corporation.  And  so  on,  and  on. 

This  remarkable  Republican  Research  Bank 
will  present  a difficult  choice  to  the  voters 
in  November:  Vote  for  the  Democrats  and 

get  a new-model  Brannan  Plan — high  prices 
to  farmers,  low  prices  to  consumers,  and  no 
cost  to  anybody;  or  vote  Republican  and  pay 
Big  Business  to  take  care  of  everything. 

Senator  Kennedy  urges  an  expansion  of  our 
foreign  dumping  program,  formally  known 
as  P.L.  480.  He  would  also — being  a red- 
blooded  American — greatly  step-up  the  give- 
aways to  the  needy  of  our  own  country. 

Kennedy,  Symington,  Johnson,  Nelson 
Rockefeller  and  Adlai  Stevenson — the  only 
serious  contenders  for  the  Presidency  besides 
Nixon — all  put  “human  values”  above  eco- 
nomic values.  They’re  so  human  they’ll  do 


OCTOBER  19^0 — VOL.  30,  NO.  4 


235 


THE  ASSOCIATION  FORUM 


anything  to  be  President.  They’re  already 
rich,  and  bless  their  hearts,  they  want  all  the 
rest  of  us  to  be,  too.  Poor-boy  Nixon,  if  elect- 
ed, will  of  course  get  rich  off  the  Presidency 
as  has  each  of  the  three  other  opportunists 
before  him — Roosevelt,  Truman  and  Eisen- 
hower. 

For  the  benefit  of  those  who  “just  came  in” 
and  those  with  short  memories.  Farm  and 
Ranch  has  relentlessly  fought  for  many  years 
this  fantastic  fraud  called  the  farm  program 
and  has  advocated  many  ways  and  measures 
to  sound,  free,  supply-and-demand  agricul- 
ture. 

The  farm  issue  is  not  cotton,  wheat,  rice. 
The  issue  is  freedom.  The  issue  is  the  Con- 
stitutional right  to  own  private  property.  If 
a person  is  denied  the  right  to  manage  his 
property,  then  he  doesn’t  really  own  it.  Bushel 
and  poundage  quotas,  income  subsidy  pay- 
ments, the  Soil  Bank,  two-price  plans — all 
have  the  same  built-in  characteristics:  denial 
of  human  freedom,  planned  peasantry.  So- 
cialism. 

Government  planning  resulted  not  in  ex- 
porting cotton,  but  in  exporting  the  right  and 
the  opportunity  to  produce  it.  And  that’s 
just  part  of  the  story.  While  American  cot- 
ton was  held  in  a government  strait  jacket, 
competing  synthetics  captured  much  of  cot- 
ton’s markets  by  default. 

American  agriculture — like  American  busi- 
ness— has  a tremendous  competitive  advan- 
tage, if  alloioed  to  compete.  American  agri- 
culture does  not  need  subsidies — at  home  or 
abroad — to  survive.  On  the  contrary  the  dead 
hand  of  government  is  suffocating  American 
agriculture  and  sponsoring  foreign  competi- 
tors. 

Foreign  steel  is  flooding  America.  Our 

manufacturers  of  barbed  wire  can’t  compete 
with  foreign  slave  labor  and  factories  given 
to  the  foreigners  by  our  own  government. 
Formerly  we  could  compete  on  almost  any- 
thing except  handmade  gadgets  by  foreign 
coolie  labor. 


Your  government,  through  abandonment 
of  the  gold  standard,  through  confiscatory 
taxation,  through  deficit  spending,  through 
government-sponsored  union  racketeering, 
through  fantastic  give-aways  at  home  and 
abroad,  through  deliberate  subsidization  of 
the  enemy — your  government  is  destroying 
the  land  of  the  free,  deliberately. 

The  American  textile  manufacturer,  for  in- 
stance, has  to  employ  workers  deliberately 
slowed  down  by  union  rackets  and  getting  a 
minimum  wage  of  $1.00  an  hour.  His  foreign 
competitor  pays  10  cents  to  15  cents  an  hour. 
The  American  manufacturer  must  pay  about 
25%  above  the  world  price  for  his  cotton. 
And  the  American  textile  manufacturer  pays 
exorbitant  taxes  to  support  the  fantastic  farm 
fraud  and  foreign  aid  insanity  which  is  forc- 
ing him  out  of  business. 

Apologists  for  agriculture  who’re  still 
pointing  an  accusing  finger  at  tariff  protec- 
tion of  business  are  whipping  a dead  mule. 
Under  present  conditions,  American  business 
needs  more  tariffs,  not  less.  However,  the 
answer  is  not  in  more  protectionism  for  busi- 
ness, but  in  less  protection  for  agriculture 
and  labor.  Permanent  protection  of  indus- 
tries, like  protection  of  individuals,  weakens 
rather  than  strengthens  them.  Unless  we 
buy  from  the  world  we  cannot  sell  to  the 
world.  We  cannot  compete  unless  we  are 
free.  Dumping  makes  enemies;  trading  makes 
friends.  Before  we  can  possibly  have  free 
trade,  we  must  regain  freedom  at  home. 

The  farmers’  problem  is  not  bad  public  re- 
lations but  bad  government.  Your  govern- 
ment is  you.  If  not  it’s  Dictatorship. 

If  the  purpose  of  agriculture  programs,  la- 
bor programs,  tax  programs,  business  pro- 
grams is  revenge  against  other  segments  of 
our  economy  then  there  is  no  end  we  can  come 
to  except  Socialism  or  Communism. 

Do  you  want  a World  Socialist  dictatorship? 
If  not,  revolt  now.  Throw  the  “liberals,”  new 
dealers,  one-worlders  out.  As  Emerson  said, 

“Of  what  avail  the  plow  or  sail 
Or  land  or  life — if  Freedom  fail!” 


236 


J.  M.  A.  ALABAMA 


Killed-Virus  Vs.  Live-Virus 

Vaccines  Against  Polio 


Thoimis  M.  Rivers,  M.  D. 


The  National  Foundation  is  often  asked 
what  its  position  is  with  respect  to  the  rela- 
tive merits  of  killed-virus  and  live-virus  vac- 
cines against  paralytic  poliomyelitis. 

The  Foundation’s  foremost  concern  is  and 
always  has  been  with  eradication  of  paralytic 
polio,  as  nearly  as  possible,  by  the  best  means. 

The  organization  neither  practices  medicine 
nor  licenses  biological  products.  Acting  as 
an  agent  of  the  American  people  whose  con- 
tributions to  the  New  March  of  Dimes  make 
its  programs  possible,  The  National  Founda- 
tion directs  and  supports  efforts,  through  sci- 
entific research,  to  solve  health  problems. 

Our  decisions  in  scientific  matters  are  made 
only  with  the  guidance  of  medical  advisors 
who  serve  on  a volunteer  basis.  To  advise  us 
on  vaccine  questions,  we  have  a Committee 
on  Virus  Vaccines,  its  members  among  the 
foremost  virologists  in  the  country. 

Beginning  in  1953 — and  continuing  even 
while  it  supported  research  by  Dr.  Jonas  E. 
Salk  and  underwrote  the  Salk  (killed-virus) 
vaccine  field  trials  and  evaluation  studies — 
The  National  Foundation  has  been  awarding 
grants  for  Dr.  Albert  B.  Sabin’s  work  in  de- 


Dr.  Rivers  is  vice  president  of  medical  affairs  of 
The  National  Foundation. 


veloping  a live-virus  vaccine  against  paralytic 
polio. 

Today,  New  March  of  Dimes  funds  are  still 
paying  for  studies  of  both  the  Salk  vaccine 
and  the  Sabin  vaccine. 

Killed-virus  vaccine:  Here  is  a brief  re- 

view of  facts  concerning  the  Salk  vaccine  at 
this  time. 

Dr.  Salk  himself  and  others  have  reported 
that  some  lots  of  commercial  vaccine  are  not 
of  optimum  potency  with  respect  to  poliovirus 
types  I and  III.  This  doubtless  accounts  for 
some  break-throughs  among  the  triply  vacci- 
nated. Some  vaccinated  persons  do  not  de- 
velop antibody  in  the  first  place,  and  in  others 
antibody  levels  fall  off  after  a period  of  time. 

According  to  Dr.  Salk,  his  laboratory-made 
vaccine  is  much  more  potent  than  the  vac- 
cine available  to  the  public.  The  means  for 
attaining  improved  potency  in  a commercial 
vaccine  may  be  available  very  soon. 

Merck  Sharp  and  Dohme  has  recently  an- 
nounced development  of  a new  Salk-type  vac- 
cine in  which  the  viruses  used  are  purified 
and  concentrated,  making  possible  a vaccine 
of  consistent  high  potency.  Application  has 
been  made  to  the  U.S.  Public  Health  Service 
for  licensing. 

Critics  of  the  Salk  vaccine  should  remem- 
ber that  the  field  trial  evaluation  report  in 


OCTOBER  I960— VOL.  30,  NO.  4 


237 


THE  ASSOCIATION  FORUM 


1955  pronounced  it  to  be  70  to  90  per  cent  ef- 
fective against  paralytic  polio,  and  no  more. 
Effectiveness  rates  today  are  higher  than  that. 
On  more  than  one  occasion,  Dr.  Alexander  D. 
Langmuir,  chief  of  the  epidemiology  branch 
of  the  Communicable  Disease  Center  of  the 
U.S.P.H.S.,  has  reported  that  figures  for  1958 
and  1959  show  the  Salk  vaccine  was  at  least 
90  per  cent  effective  in  preventing  paralysis. 
He  says  that  surveillance  reports  clearly  in- 
dicate “our  failure  in  this  country  to  achieve 
adequate  control  of  poliomyelitis  is  due  to  our 
failure  to  achieve  adequate  utilization  of  the 
vaccine  rather  than  to  failure  of  the  vaccine 
itself.” 

A number  of  scientific  authorities  make  this 
further  important  point  for  killed-virus  vac- 
cine: Salk  vaccine  has  been  successfully  com- 
bined with  diphtheria-whooping  cough-tet- 
anus vaccine,  making  a single  product  that 
immunizes  against  four  diseases.  This  sug- 
gests that  as  other  killed-virus  vaccines 
against  other  virus  diseases  are  developed, 
they  too  can  be  combined  in  the  multiple 
preparation.  This  advantage  would  not  be 
possible  with  vaccines  of  the  live-virus  type. 

Live-virus  vaccines:  Proponents  of  oral 

vaccines  assume  and  expect  these  vaccines 
will  have  the  following  advantages  over  vac- 
cines of  the  killed-virus  type:  cheaper 

to  make,  easier  to  administer,  quicker  devel- 
opment of  antibodies,  greater  effectiveness, 
longer-lasting  immunity,  and  potential  for 
eradication  of  polioviruses  through  vaccina- 
tion by  contact  spread. 

Concerning  the  three  oral  polio  vaccines, 
these  facts  seem  significant:  1)  In  laboratory 
safety  tests,  in  which  the  attenuated  strains 
are  injected  directly  into  the  central  nervous 
systems  (spinal  cord  and  brain)  of  monkeys, 
both  Melnick  and  Sabin  have  reported,  and 
the  Public  Health  Service  has  confirmed,  that 
Sabin  strains  are  consistently  less  virulent 
than  Lederle  and  Koprowski  strains;  2)  the 
Sabin  experimental  vaccine  has  been  more 
widely  field-tested  than  the  others,  having 
been  fed  to  more  than  50,000,000  people  in  the 
Soviet  Union  and  to  several  millions  more  in 


Czechoslovakia,  Mexico,  Singapore,  Chile, 
Japan,  and  Holland. 

There  is  still  today  widespread  agreement 
among  distinguished  scientists  that  though 
live-virus  vaccines  against  polio  show  great 
promise,  certain  key  problems  have  not  been 
satisfactorily  solved  and  should  be  investi- 
gated. 

Recommendations  to  this  effect  have  been 
made  by  1)  The  National  Foundation’s  Ad- 
visory Committee  on  Virus  Vaccines;  2)  by 
the  United  States  Public  Health  Service;  and 
3)  in  the  summary  report  of  the  International 
Conference  on  Live  Poliovirus  Vaccines  held 
in  Washington  in  June,  1959,  a meeting  ad- 
dressed by  some  of  the  world’s  foremost  vi- 
rologists, including  Drs.  Sabin,  Koprowski, 
and  Melnick;  and  4)  by  Dr.  David  Bodian, 
noted  virologist  at  Johns  Hopkins  University, 
addressing  the  “1960  Symposium  on  Polio 
Vaccines”  held  in  Newark,  N.  J.,  in  April, 
1960. 

Here  are  some  of  the  valid  questions  con- 
cerning the  safety  and  effectiveness  of  live- 
virus  vaccines  that  have  not  yet  been  answer- 
ed to  the  satisfaction  of  scientific  authorities: 

1)  Safety.  Attenuated  virus  strains  in 
present  experimental  vaccines  have  been  ob- 
served to  revert  to  more  potent  strains  after 
a succession  of  human  passages.  They  have 
not  been  found  to  regain  all  their  original 
virulence,  but  the  fact  they  revert  at  all  indi- 
cates they  are  not  genetically  stable.  No  one 
seriously  considers  there  is  any  risk  to  the 
original  vaccine.  Nor  does  there  seem  to  be 
any  risk  to  vaccine  contacts.  But  conserva- 
tive scientists  point  out  that  we  do  not  have 
irrefutable  proof. 

2)  Interference  and  Effectiveness.  To  be 
effective,  the  three  live-virus  strains  in  the 
vaccines  must  multiply  in  the  intestinal  tract 
of  the  vaccinees.  Frequently,  other  viruses 
already  present  in  the  intestinal  tracts  of  vac- 
cinated persons  interfere  with  and  prevent 
multiplication  of  vaccine  viruses  there.  This 
is  known  as  the  interference  phenomenon. 
It  happens  inconsistently  and  unpredictably 


238 


J.  M.  A.  ALABAMA 


THE  ASSOCIATION  FORUM 


and  varies  in  different  parts  of  the  world. 
For  this  reason,  it  is  impossible  to  guarantee 
a “take”  with  the  oral  vaccines.  In  an  im- 
munization program,  you  can’t  know  in  ad- 
vance what  viruses  everyone  is  carrying  at 
the  time  of  vaccination;  so  effectiveness  is  in 
doubt.  Tests  are  being  conducted  to  seek 
methods  for  overcoming  this  problem.  They 
look  promising,  but  the  answers  are  not  likely 
to  come  overnight. 

The  claim  that  oral  vaccines  provide  long- 
lasting  immunity,  comparable  to  that  induced 
by  infection  by  wild  polioviruses,  has  not 
been  conclusively  demonstrated.  Passage  of 
sufficient  time  alone  can  prove  this  one  way 
or  the  other. 

3)  Dosage  and  Administration  Schedule. 
There  is  still  no  agreement  among  oral  vac- 
cine experts  on  the  best  dosage  and  vaccina- 
tion schedule.  Because  the  three  virus  strains 
in  the  vaccines  themselves  can  interfere  with 
each  other,  in  the  majority  of  recent  field 
tests  the  three  types  have  been  given  in  sepa- 
rate doses  a month  to  six  weeks  apart.  Soviet 
authorities  are  reported  considering  g